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PLASTIC  AND 
COSMETIC  SURGERY 


"FATHER  OF  PLASTIC  SURGERY." 


PLASTIC  AND 
COSMETIC  SURGERY 


FREDERICK^STRANGE    KOLLE,  M.D. 

FKLLOW  OF  NEW  YORK  ACABEMY  OF  MEDltlJ?E;  MEMBER  OF  DEUTSCHE  MEDEZIN- 

ISCHE  GKSELLSCHAFT,  V.  Y.,  KINGS  COVNTY  HOSPITAL  ALUMNI  SOCIETY, 

AUTHORS'  COMMITTEE  AMERICAN  HEALTH  LEAGUE,  PHYSICIANS' 

LEGISLATURE  .LEAGUE/ffiTC.  JWUJTHOR  OF   "THE  X-RAYS: 

THEIR  PRODUCTION  AND  APPLICATION,"  "MKDICO- 

-  *U«GICAL  RABIOGfeAT^HY,"  "SUBCUTANEOUS 

HYDROCARBON  PROTHESES,"  ETC. 

M 


WITH  (^fE  COLORED  PLATE  AND  FIVE  HUNDRED  AND 
TWENTY-TWO  ILLUSTRATIONS  IN   TEXT 


NEW     YORK     AND     LONDON 

D.     APT  I,  ETON     AND     COMPANY 

1911 


COPYRIGHT,  1911,  BY 
D.  APPLETON   AND  COMPANY 


PRINTED  AT  THE  APPLETON  PRESS, 
NEW  YORK,  U.  S.  A. 


TO 

ALPHONZO  BENJAMIN  BOWERS 

WHO   KINDLED   THE   FIRE   OF   MY  AMBITION 

AND   KEPT   IT   BURNING   BY 
HIS    INTEREST   AND   UNTIRING   APPRECIATION 

THIS   WORK   IS 

WITH   HEARTFELT   GRATITUDE 
INSCRIBED 


PKEFACE 


THE  object  of  the  author  has  been  to  place  before  the 
profession  a  thoroughly  practical  and  concise  treatise 
on  plastic  and  cosmetic  surgery.  The  importance  of  this 
branch  of  practice  is  at  the  present  time  undeniable,  yet 
the  literature  on  this  subject  is  widely  scattered  and 
scanty.  It  consists  mostly  of  small,  detached  papers  or 
reports  in  different  countries,  with  an  occasional  refer- 
ence in  text-books  on  general  surgery. 

The  author  feels,  from  the  numerous  inquiries  made 
him  by  physicians  from  many  parts  of  the  world  con- 
cerning methods  herein  described,  that  there  is  now  an 
actual  need  for  an  authoritative  work  on  this  subject. 

Great  care  has  been  taken  to  select  the  best  matter 
and  to  present  it  with  comprehensive  illustrations  every 
physician  can  readily  and  confidently  refer  to. 

Skin-grafting  has  been  particularly  gone  into,  as  well 
as  electrolysis  as  applied  to  dermatology,  with  informa- 
tion as  to  the  construction  and  scientific  use  of  apparatus 
involved. 

To  the  whole  has  been  added  the  practical  experience 
and  criticism  of  the  author,  who  has  devoted  many  years 
to  the  scientific  and  faithful  advancement  of  this  spe- 
cialty. 

FREDERICK  STRANGE  KOLLE. 

12  EAST  THIRTY-FIRST  STREET, 
NEW  YORK  CITY. 


CONTENTS 


CHAPTER  I 

HISTORICAL 

Historical 


CHAPTER  II 

REQUIREMENTS   FOR   OPERATING 

The  operating  room:  The  walls;  The  floors;  Skylight;  Disinfection;  In- 
strument cabinet;  Operating  table;  Instrument  table;  Irrigator  — 
Care  of  instruments  —  Preparation  of  the  surgeon  and  assistants: 
Care  of  the  hands;  Gowns  —  Preparing  the  patient:  General  prepara- 
tion; Preparation  of  the  operative  field  .......  9 

CHAPTER   III 

REQUIREMENTS    DURING    OPERATION 

Sponges  and  sponging  —  Sterilization  of  dressings:  Wallace  sterilizer; 
Sprague  sterilizer;  Sterilizing  plant;  Dressing  cases;  Waste  cans  —  • 
Sutures  and  sterilization:  Silkworm  gut  and  silk;  Catgut  ...  22 

CHAPTER  IV 
PREFERRED   ANTISEPTICS 
Antiseptic  solutions  —  Antiseptic  powders      .......       34 


Sutured  wounds — Sutureless  coaptation — Granulation — Changing  dress- 
ings— Wounds  of  the  mucous  membrane — Pedunculated  flaps — For- 
eign bodies  ....  43 

CHAPTER  VI 

SECONDARY   ANTISEPSIS 

Septicemia  following  wound  infection — Gangrene — Erysipelatous  infec- 
tion  52 

ix 


x  CONTENTS 

CHAPTER  VII 

ANESTHETICS 

PAGE 

General  anesthesia:  Preparation  for  general  anesthesia;  Chloroform; 
Ether;  Combined  anesthesia;  Nitrous  oxid;  Ethyl  bromid;  Ethyl 
chlorid — Local  anesthesia:  Ethyl  chlorid;  Cocain;  Beta  eucain; 
Liquid  air;  Stovain 58 

CHAPTER   VIII 
PRINCIPLES   OF   PLASTIC   SURGERY 

Incisions — Sutures — Needles — Needle  holders — Methods  in  plastic  op- 
erations: Stretching  method;  Sliding  method;  Twisting  method; 
Implantation  of  pedunculated  flaps  by  bridging;  Transplantation  of 
nonpedunculated  flaps  or  skin-grafting;  Autodermic  skin-grafting; 
Heterodermic  skin-grafting;  Zoodermic  skin-grafting — Mucous- 
membrane-grafting — Bone-grafting — Hair-transplantation  .  .  76 

CHAPTER  IX 

BLEPHAROPLASTY 

Ectropion:  Partial  ectropion;  Complete  ectropion;  Ectropion  of  both 
lids  —  Epicanthus  —  Canthoplasty  —  Ptosis  —  Ankyloblepharon — 
Wrinkled  eyelids — Xanthelasma  palpebrarum 103 

CHAPTER  X 

OTOPLASTY 

Restoration  of  the  auricle — Auricular  protheses — Coloboma — Malfor- 
mation of  the  lobule:  Enlargement  of  the  lobule;  Attachment  of  the 
lobe — Malformation  of  the  auricle:  Microtia — Auricular  Appendages 
— Polyotia — Malposition  of  the  auricle 120 

CHAPTER  XI 

CHEILOPLASTY 

Harelip:  Classification  of  harelip  deformities;  The  operative  correction 
of  harelip;  Of  unilateral  labial  cleft;  Of  congenital  bilateral  labial 
cleft;  Postoperative  treatment  of  harelip — Superior  cheiloplasty: 
Classification  of  deformities  of  the  upper  lip;  Operative  correction  of 
deformities  of  the  upper  lip — Inferior  cheiloplasty — Labial  deficiency 
— Labial  ectropion — Labial  entropion — Vermilion  deficiency  .  .  145 

CHAPTER  XII 

STOMATOPLASTY 

The  correction  of  macrostoma — The  correction  of  microstoma   .  192 


CONTENTS  xi 

CHAPTER  XIII 

MELOPLASTY 

PAGE 

Small  and  medium  defects — Large  defects — Employment  of  protheses     .     198 

CHAPTER  XIV 
SUBCUTANEOUS   HYDROCARBON   PROTHESES 

Indications — Precautions — The  advantage  of  the  method — Untoward 
results:  Intoxication;  Reaction;  Infection;  Necrosis;  Sloughing; 
Sloughing  due  to  pressure;  Subinjection;  Hyperinjection;  Air  embol- 
ism; Paraffin  embolism;  Primary  diffusion  or  extension  of  paraffin; 
Interference  with  muscular  action  of  the  wings  of  the  nose;  Escape 
of  paraffin  after  withdrawal  of  needle;  Solidification  of  paraffin  in 
needle;  Absorption  or  disintegration  of  the  paraffin ;  The  difficulty  of 
procuring  paraffin  with  proper  melting  point;  Hypersensitiveness  of 
skin;  Redness  of  the  skin;  Secondary  diffusion  of  the  injected  mass; 
Ilyperplasia  of  the  connective  tissue  following  the  organization  of 
injected  matter;  Yellow  appearance  and  thickening  of  the  skin  after 
organization  of  the  injected  mass  has  taken  place;  The  breaking 
down  of  tissue  and  resultant  abscess  due  to  the  pressure  of  the 
injected  mass  upon  the  adjacent  tissue  after  the  injection  has 
become  organized — The  proper  instruments  for  the  subcutaneous 
injection  of  hydrocarbon  protheses — Preparation  of  the  site  of  oper- 
ation— Preparation  of  the  instruments  for  operation — The  practical 
technique — Specific  classification  for  the  employment  and  indication 
of  hydrocarbon  protheses  about  the  face — Specific  classification  for 
the  employment  and  indication  of  hydrocarbon  protheses  about  the 
shoulders,  etc. — Specific  technique  for  the  correction  of  regional  de- 
formities about  the  face'.  Transverse  depressions;  Deficient  or  reced- 
ing forehead;  Unilateral  deficiency;  Interciliary  furrow;  Temporal 
muscular  deficiency;  jDeformities  of  the  nose;  Deformities  about  the 
mouth;  Deformities  about  the  cheeks;  Deformities  about  the  orbit; 
Deformities  about  the  chin;  Deformities  about  the  ear — Specific 
technique  for  the  correction  of  deformities  about  the  shoulders  .  .  209 

CHAPTER  XV 

RHINOPLASTY 

The  causes  of  nasal  destruction — Classification  of  deformities — Surgical 
technique — Protheses — Nasal  replanting — Nasal  transplanting — 
Total  rhinoplasty :  Pedunculated  flap  method ;  The  Indian  or  Hindu 
method;  The  French  method;  The  Italian  method;  The  combined 
flap  method;  Organic  support  of  nasal  flaps;  Periostitic  supports; 
Osteoperiostitic  supports;  Cartilaginous  support  of  flap — Partial  rhi- 
noplasty; Restoration  of  base  of  nose;  Restoration  of  lobule  and 
alae;  Restoration  of  the  alse;  Restoration  of  nasal  lobule;  Restoration 
of  subseptum 339 


xii  CONTENTS 

CHAPTER  XVI 

COSMETIC    RHINOPLASTY 

PAGE 

Angular  nasal  deformity — Correction  of  elevated  lobule — Correction  of 
bulbous  lobule — Angular  excision  to  correct  lobule — Correction  of 
malformations  about  nasal  lobule — Deficiency  of  nasal  lobule — Cor- 
rection of  widened  base  of  nose — Reduction  of  thickness  of  alse — 
Correction  of  nasal  deviation — Undue  prominence  of  nasal  process 
of  the  superior  maxillary 448 


The  electric  battery — The  voltage  or  electromotive  force — Cell  selector 
— Milliamperemeter — The  electric  current — Portable  batteries — 
Electrodes — Removal  of  superfluous  hair — Removal  of  moles  or 
other  facial  growths — Telangiectasis — Removal  of  nsevi — Removal 
of  tattoo  marks — The  treatment  of  scars 470 

CHAPTER  XVIII 

CASE   RECORDING    METHODS 

Photographs — Stencil  record — The  rubber  stamp — The  plaster  cast — 

Preparation  of  photographs    .        . 491 


LIST  OF  ILLUSTRATIONS 


FIQ.  PAGE 

A.  Cornelius  Celsus  ("  Father  of  Plastic  Surgery  ")  .        Frontispiece 

HISTORICAL 

1. — Celsus  incision  for  restoration  of  defect 2 

2. — Celsus  incision  to  relieve  tension 2 

REQUIREMENTS  FOR  OPERATING 

3. — Formaldehyd  disinfecting  apparatus 11 

4. — Instrument  cabinet 12 

5. — Operating  table 13 

6. — Instrument  table 14 

7. — Irrigator 15 

8. — Instrument  sterilizer 16 

9. — Aseptic  washstand 17 

10. — Von  Bergman  operating  gown 19 

11. — Triffe  rubber  apron 19 

REQUIREMENTS  DURING  OPERATION 

12. — Basins  and  rack 23 

13. — Willy  Meyer  sterilizer 25 

14. — Wallace  sterilizer 25 

15. — Sprague  type  of  sterilizer 26 

16. — Sterilizing  plant 28 

17. — Dressing  case 29 

18. — Combination  dressing  case  and  table 29 

19.— Waste  pail 30 

20. — Clark  Kumol  apparatus 32 

WOUND  DRESSING 

21,  22.— Plaster  sutures 46 

23,  24. — Angular  plaster  sutures 46 

SECONDARY  ANTISEPSIS 

25. — Walcher  dressing  forceps 55 

26. — Toothed  seizing  forceps 55 

xiii 


xiv  LIST    OF    ILLUSTRATIONS 

ANESTHETICS 

FIQ.  PAGE 

27. — Schimmelbusch  dropping  bottle 60 

28. — Esmarch  dropping  bottle 60 

29. — Schimmelbusch  folding  mask 61 

30. — Esmarch  inhaler 61 

31.— Allis  inhaler 65 

32. — Fowler  inhaler 65 

33.— Juillard  mask 66 

34. — Simplex  syringe 72 

35. — Kolle  improved  Pravaz  syringe 72 

36.— "Sub-Q"  syringe 72 

PRINCIPLES  OP  PLASTIC  SURGERY 

37. — |  circle  Haagedorn  needles 77 

38. — Crescent  curve  Haagedorn  needles 77 

39. — Kersten-Mathieu  needle  holder 78 

40. — Haagedorn  needle  holder 78 

41. — Pozzi-Haagedorn  needle  holder 78 

42. — Weber-Haagedorn  needle  holder 78 

43. — Needleholder  with  suture  carrier 78 

44. — Celsus  skin  incisions 80 

44a. — Celsus  relieving  incisions 80 

45. — Rhomboid  excision 80 

46. — Union  of  rhomboid  excision 80 

47. — Oblong  excision 81 

48. — Coaptation  of  wound 81 

49. — Bitriangular  excision 81 

50. — Linear  coaptation 81 

51. — Triangular  excision 81 

52. — Coaptation  of  wound 81 

53. — Triangular  excision  with  relieving  incisions 82 

54. — Coaptation  of  wound 82 

55. — Square  excision 82 

56. — Coaptation  of  wound 82 

57. — Square  excision 82 

58. — Coaptation  of  flaps 82 

59. — Triangular  excision 83 

60.— Coaptation  of  flap 83 

61. — Triangular  excision 83 

62. — Coaptation  of  flaps 83 

63. — Triangular  excision 83 

64. — Arrangement  of  flaps 83 

65. — Double  triangular  excision 84 

66. — Coaptation  of  wound 84 

67. — Tritriangular  excision 84 

68. — Coaptation  of  wound 84 


LIST    OF    ILLUSTRATIONS  xv 

PIQ.  PAGE 

69. — Rectangular-bitriangular  excision 84 

70. — Coaptation  of  wound     ...                84 

71. — Weber  excision  method 85 

72. — Coaptation  of  flaps        .        .                85 

73. — Elliptical  excision           .        .                85 

74. — Coaptation  of  flaps        .  85 

75. — Triangular  excision        ....                86 

76. — Coaptation  of  flaps        ....                86 

77. — Triangular  excision 86 

78. —Coaptation  of  flaps 86 

79. — Lentenner  method  of  excision 86 

80.— Coaptation  of  flap          .                        86 

81. — Burns  method  of  excision 87 

82. — Coaptation  of  flaps 87 

83. — Tagliacozza  harness 87 

84. — Smith  skin-grafting  scissors 89 

85. — Thiersch  skin-grafting  razor 93 

86. — Thiersch  folding  razor 93 

87. — Method  of  cutting  Thiersch  graft 94 

88. — Method  of  placing  Thiersch  graft 95 

BLEPHAROPLASTY 

89. — Correction  of  ectropion,  Dieffenbach  method 104 

90  a  and  b. — Correction  of  partial  ectropion  (author's  case)   .        .        .  104 

91,  92. — Complete  ectropion,  Dieffenbach  method 106 

93,  94. — Complete  ectropion,  Wolfe  method 107 

95,  96. — Complete  ectropion,  Fricke  method 108 

97,  98. — Complete  ectropion,  Ammon-von  Langenbeck  method    .        .  109 

99,  100. — Complete  ectropion,  Dieffenbach-Seere  method       .        .        .110 

101,  102,  103.— Complete  ectropion,  Tripier  method         .        .        .        .111 

104,  105. — Complete  ectropion,  Von  Artha  method 112 

106,  107.— Epicanthus,  Bull  method     .        .        .        .        .        .        .        .113 

108. — Probe-pointer  angular  scissors 114 

109,  110,  111. — External  canthoplasty 115 

112,  113. — Blepharoplastics,  author's  method 116 

114. — Curved  eye  scissors 117 

OTOPLASTY 

115. — Partial  restoration  of  the  auricle 124 

116. — Correction  of  lobular  defect 126 

117. — Coaptation  of  wound 126 

118,  119. — Greene  method  correcting  coloboma 126 

120.— Noyes's  clamp 127 

121,  122.— Correction  of  attached  lobe .  128 

123. — Restoration  of  auricle,  Szymanowski  method            ....  129 

124. — Auricular  stump  for  attachment  of  artificial  ear      ....  130 

125. — Auricular  prothesis 130 

1 


xvi  LIST    OF    ILLUSTRATIONS 

FIO.  PAGE 

126. — Auricular  prothesis  applied  to  stump 131 

127. — Anterior  view  of  auricular  prothesis 131 

128. — Posterior  view  of  auricular  prothesis 131 

129,130,131. — Schwartze  method  of  correction  of  macrotia    .        .        .  134 

132,  133. — Parkhill  method  of  correction  of  macrotia        ....  135 

134,  135. — Author's  method  of  correction  of  macrotia       ....  137 

136,  137. — Author's  method  of  correction  of  macrotia       ....  137 

138. — Monks'  method  of  correction  of  malposed  ear  .                        .  139 

139,  140. — Author's  method  of  correction  of  malposed  ear       .        .        .  140 

141,  142. — Correction  of  malposed  auricles,  author's  case  (anterior  view)  142 

143,  144. — Posterior  view  of  replaced  auricles 143 

CHEILOPLASTY 

145. — Burchardt  compression  forceps 145 

146. — Beinl  harelip  clamp 145 

147. — Median  cleft,  Siegel's  case 147 

148. — Median  cleft  with  rhinophyma,  Trendelenburg's  case     .        .        .  147 

149,  150,  151.— Types  of  unilateral  labial  cleft 148 

152. — Unilateral  facial  cleft,  Hasselmann 149 

153. — Bilateral  facial  cleft,  Guersant 149 

154. — Buccal  fissure  with  macrostoma 150 

155,  156,  157. — Harelip  correction,  Nelaton  method          ....  152 

158,  159. — Harelip  correction,  Fillebrown  method 153 

160,    161,    162. — Harelip    correction,    Von    Langenbeck-Wolff-Sedillot 

method 153 

163,  164,  165. — Harelip  correction,  Malgaigne  method      ....  154 

166,  167. — Harelip  correction,  Grafe  method 154 

168,  169,  170. — Harelip  correction,  Mirault  method 155 

171,  172,  173. — Harelip  correction,  Giralde  method 155 

174,  175,  176. — Harelip  correction,  Konig  method 156 

177,  178,  179. — Harelip  correction,  Maas  method 156 

180,  181,  182. — Harelip  correction,  Haagedorn  method     ....  157 

183,  184,  185. — Harelip  correction,  Dieffenbach  method   ....  157 

186,  187. — Correction  bilateral  cleft,  Von  Esmarch  method     .       .        .  159 
188,  189,  190.— Correction  bilateral  cleft,  Maas  method   .        .        .        .159 

191,  192,  193. — Correction  bilateral  cleft,  Haagedorn  method          .        .  160 

194,  195,  196. — Correction  bilateral  cleft,  Simon  method          .        .        .  160 

197. — Hainsley  cheek  compressor 161 

198,  199. — Superior  cheiloplasty,  Bruns  method 164 

200,  201.— Superior  cheiloplasty,  Sedillot  method 165 

202. — Superior  cheiloplasty,  Buck  method 165 

203,  204,  205.— Superior  cheiloplasty,  Estlander  method  .        .        .        .166 

206,  207. — Inferior  cheiloplasty,  Richeraud  method 169 

208,  209. — Extirpation  of  vermilion  border 169 

210,  211. — Inferior  cheiloplasty,  Celsus  method  with  additional  incisions  170 

212,  213. — Inferior  cheiloplasty,  Estlander  method 171 

214,  215. — Inferior  cheiloplasty,  Bruns  method 172 


XV11 

FIG.  PAGE 

216,  217.— Inferior  cheiloplasty,  Buck  method 172 

218,  219.— Inferior  cheiloplasty,  Dieffenbach  method        .        .        .        .173 

220,  221. — Inferior  cheiloplasty,  Jasche  method 174 

222,  223.— Inferior  cheiloplasty,  Trendelenburg  method    ....  174 

224,  225. — Inferior  cheiloplasty,  Bruns  method 175 

226,  227. — Inferior  cheiloplasty,  Bruns  bilateral  method           .        .        .  175 
228,  229,  230.— Inferior  cheiloplasty,  Buchanan  method   .        .        .        .176 

231,  232. — Inferior  cheiloplasty,  Syme  method 177 

233,  234. — Inferior  cheiloplasty,  Blasius  method 178 

235,  236. — Inferior  cheiloplasty,  Biirow  method 178 

237,  238. — Inferior  cheiloplasty,  von  Langenbeck 179 

239,  240. — Inferior  cheiloplasty,  Morgan  method 180 

241,  242. — Inferior  cheiloplasty,  Zeis  method 181 

243,  244. — Inferior  cheiloplasty,  Delpech  method 182 

245,  246. — Inferior  cheiloplasty,  Teale  method  .        .        .        .        .        .185 

247,  248. — Labial  ectropion,  author's  method 187 

219,  250. — Labial  ectropion,  author's  method '  188 

STOMATOPLASTY 

251,  252. — Correction    of    Macrostoma,    Dieffenbach-von    Langenbeck 

method 193 

253,  254. — Correction  of  Macrostoma,  author's  method    ....  195 

255,  256. — Correction  of  Microstoma,  Dieffenbach  method      .        .        .  196 

257. — Artificial  mouth,  Heuter 196 

MELOPLASTY 

258,  259.— Meloplasty,  Serre  method 199 

260,  261.— Correction  of  angle  of  mouth 200 

262,  263. — Correction  of  extensive  angle  of  mouth 200 

264,  265. — Meloplasty,  Kraske  method 201 

266,  267,  268.— Meloplasty,  Israel  method 202 

269,  270.— Meloplasty,  Bardenheuer 202 

271,  272,  273,  274.— Meloplasty,  Bardenheuer 203 

275,  276,  277,  278.— Meloplasty,  Bardenheuer .204 

279,  280.— Meloplasty,  Staffel 205 

281. — Cheek  prothesis  after  removal  of  sarcoma,  Martin.        .        .        .  206 

282.— Prothesis  applied  to  face       .        .        . 207 

SUBCUTANEOUS  HYDROCARBON  PROTHESES 

283. — Circulation  of  the  head  (author) Facing  210 

284. — Eckstein  insulated  syringe 232 

285.— Quinlan  paraffin  heater 232 

286. — Author's  electrothermic  paraffin  heater 244 

287.— Smith  paraffin  heater 246 

288a,  288b. — Microphotograph,  showing  fibromatosis        .        .       Facing  258 

289. — Author's  drop  syringe 265 

290.— Author's  all-metal  syringe 266 


XV111 

FIQ.  PAGE 

291. — Smith's  all-metal  syringe 267 

292,  293. — Anterior  superior  third  nasal  deficiency  and  correction  thereof  289 

294,  295. — Anterior  median  third  nasal  deficiency  and  correction  thereof  292 

296,  297. — Anterior  inferior  third  nasal  deficiency  and  correction  thereof  294 
298a,  2986. — Anterior  superior  and  inferior  third  nasal  deficiency  and 

correction  thereof 301 

299,  300. — Anterior  total  nasal  deficiency  and  corrections  thereof  .  .  303 
301. — Untoward  effect  of  paraffin  injection  about  lobule  and  anterior 

nasal  line 311 

302,  303. — Profile  view,  showing  correction  of  antero-lateral  deficiency 

about  chin 330 

304,  305. — Frontal  view,  showing  correction  of  antero-lateral  deficiency 

about  chin;  also  correction  of  deficiency  of  cheeks       .        .       .  332 

RHINOPLASTY 

306. — Deficiency  of  superior  and  middle  third  of  nose       ....  342 

307. — Post-ulcerative  deformity  of  superior  third  of  nose         .        .        .  342 

308. — Loss  of  right  ala,  lobule  and  columna 342 

309. — Loss  of  lobule,  inferior  septum  and  columna 342 

310.— Ulcerative  loss  of  right  median  lateral  skin  of  nose.        .        .        .  343 

311. — Loss  of  nasal  bones,  partial  dorsum,  lobule  and  septum         .        .  343 

312. — Destruction  of  nasal  bones  with  dorsum  and  lobule  intact     .        .  343 

313.— Total  loss  of  nose 343 

314,  315,  316.— Koomas  method  of  rhinoplasty 353 

317. — Graefe  method  of  rhinoplasty 353 

318,  319,  320,  321.— Delpech  method  of  rhinoplasty         .        .        .        .354 

322,  323.— Lisfranc  method  of  rhinoplasty 355 

324. — Labat  method  of  rhinoplasty 356 

325.— Keegan  method  of  rhinoplasty .  356 

326. — Duberwitsky  method  of  rhinoplasty 357 

327. — Dieffenbach  method  of  rhinoplasty 357 

328. — Von  Ammon  method  of  rhinoplasty 358 

329. — Auvert  method  of  rhinoplasty 358 

330. — Von  Langenbeck  method  of  rhinoplasty 359 

331,  332.— Petrali  method  of  rhinoplasty 360 

333. — Forgue  method  of  rhinoplasty 361 

334. — D'Alguie  method  of  rhinoplasty 361 

335. — Landreau  method  of  rhinoplasty 361 

336. — Von  Langenbeck  method  of  rhinoplasty 361 

337. — Von  Langenbeck  method  of  rhinoplasty 362 

338. — Szymanowski  method  of  rhinoplasty 362 

339. — N61aton  method  of  rhinoplasty .        .  365 

340. — Heuter  method  of  rhinoplasty     ....                              .  365 

341. — Biirow  method  of  rhinoplasty 365 

342. — Szymanowski  method  of  rhinoplasty 366 

343,  344. — Serre  method  of  rhinoplasty 367 

345,  346. — Maisonneuve  method  of  rhinoplasty 369 


LIST    OF    ILLUSTRATIONS  xix 

FIG.  PAGE 

347,  348,  349.— Dieffenbach  arm-flap  method 373 

350. — Szymanowski  arm-flap  method 375 

351. — Fabrizi  arm-flap  method 376 

352,  353. — Steinthal  thoracic  flap  method 377 

354,  355. — Volkman  method  of  rhinoplasty 379 

356. — Keegan  method  of  rhinoplasty 380 

357,  358.— Verneuil  method  of  rhinoplasty 380 

359,  360.— Thiersch  method  of  rhinoplasty 381 

361,  362.— Helferich  method  of  rhinoplasty 382 

363,  364.— Sedillot  method  of  rhinoplasty 383 

365. — Berger  arm-flap  method 385 

366. — Berger  retention  apparatus 385 

367,  368. — Szymanowski  rhinoplasty  method 386 

369. — Konig  rhinoplasty  method 391 

370. — Von  Hacker  rhinoplasty  method,  arrangement  of  frontal  flap  to 

allow  chiseling 392 

371. — Von  Hacker  rhinoplasty  method,  making  osteo-periostic  support  392 

372. — Von  Hacker  rhinoplasty  method,  bone-lined  flap  in  position  .  392 

373,  374. — Rotter  rhinoplastic  method 394 

375,  376.— Schimmelbusch  frontal  flap  method 395 

377,  378. — Helferich  rhinoplasty  method 397 

379,  380,  381.— Krause  rhinoplasty  method 399 

382.— Nelaton  rhinoplasty  method 400 

383. — Nelaton  rhinoplasty  method,  making  bony  support  .  .  .  400 

384. — Nelaton  rhinoplasty  method,  cutting  through  bony  plate  .  .  401 

385. — Nelaton  rhinoplasty  method,  disposition  of  frontal  flap  .  .  401 

386. — Israel  method,  forearm  flap 402 

387. — Israel  method,  position  of  forearm  to  place  flap  ....  403 

388. — Nelaton  method,  outlining  frontal  flap 407 

389. — Nelaton  method,  locating  cartilage  strip 408 

390.— Nelaton  method,  excision  of  cartilage  strip 409 

391. — Nelaton  method,  placing  of  cartilage  strip 410 

392. — Nelaton  method,  bringing  down  frontal  flap 411 

393. — Nelaton  method,  placing  frontal  flap 411 

394,  395. — Steinhausen  partial  rhinoplasty  method 412 

396,  397. — Neumann  partial  rhinoplasty  method 413 

398,  399,  400. — Later  Neumann  partial  rhinoplasty  method  .  .  .  415 

401. — Bardenheuer  method,  shape  of  flap 416 

402. — Bardenheuer  method,  disposition  of  flap 416 

403.— Oilier  method  first  step 417 

404. — Oilier  method,  second  step 418 

405. — Oilier  method,  position  nasal  bone  occupies 418 

406. — Von  Langenbeck  method,  first  step 419 

407. — Von  Langenbeck  method,  showing  separation  and  elevation  of 

nose  flaps 419 

408.— Nelaton  method,  first  step 421 

409. — Nelaton  method,  making  lower  nasal  flap 421 

410. — Nelaton  method,  forming  base  of  nose 422 


xx  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

411. — Ne"laton  method,  ultimate  disposition  of  flap 422 

412. — Bayer-Payr  restoration  of  lobule,  first  step 425 

413. — Bayer-Payr  restoration  of  lobule,  disposition  of  flaps      .        .        .  425 

414. — Bayer-Payr  restoration  of  lobule,  placing  of  pedicles  after  division  425 

415. — Ch.  Nelaton  method,  attachment  of  forearm  flap    ....  426 

416. — Ch.  Nelaton  method,  forearm  flap  in  position,  lateral  flaps  .        .  426 

417. — Ch.  Nelaton  method,  disposition  lateral  flaps  ....  426 

418. — Denonvillier  method,  making  of  flap  for  ala 428 

419. — Denonvillier  method,  disposition  of  flap  for  anterior  pedicle  ala  .  428 

420. — Denonvillier  method,  making  of  flap  for  ala,  posterior  pedicle     .  428 

421. — Denonvillier  method,  disposition  of  flap  for  ala,  posterior  pedicle.  428 

422,  423. — Mutter  method  of  restoration  of  ala 429 

424,  425. — Von  Langenbeck  method  of  restoration  of  ala         .        .        .  430 

426. — Busch  method  of  restoration  of  ala 430 

427. — Dieffenbach  method  of  restoration  of  ala 431 

428. — Dupuytren  method  of  restoration  of  ala 431 

429. — Fritz-Reich  method  of  restoration  of  ala 431 

430,  431,  432,  433.— Sedillot  method  of  restoration  of  ala         ...  432 

434,  435. — Nelaton  method  of  restoration  of  ala 433 

436,  437. — Bonnet  method  of  restoration  of  ala 434 

438,  439.— Weber  method  of  restoration  of  ala 434 

440. — Thompson  mucosa  flap 435 

441,  442. — Thompson  method  of  restoration  of  ala 435 

443,  444. — Blandin  method  of  restoration  of  ala 436 

445,  446. — Von  Hacker  method  of  restoration  of  ala          ....  436 

447,  448. — Kolle  method  of  restoration  of  ala 437 

449. — Denonvillier  method  of  restoration  of  ala 438 

450,451,452. — Von  Hacker  method  of  restoration  of  ala .        .        .        .  439 

453. — Konig  method  of  restoration  of  ala 440 

454,  455. — Kolle  method  of  restoration  of  ala 441 

456,  457. — Kolle  method  of  restoration  of  lobule 442 

458,  459. — Blandin  method  of  restoration  of  subseptum    ....  444 

460,  461. — Dupuytren  method  of  restoration  of  subseptum      .        .        .  445 

462. — Serre  method  of  restoration  of  subseptum 445 

463,  464. — Dieffenbach  method  of  restoration  of  subseptum    .        .        .  446 

465. — Heuter  method  of  restoration  of  subseptum 446 

466. — Szymanowski  method  of  restoration  of  subseptum   ....  446 

467,  468. — Szymanowski  method  of  restoration  of  subseptum         .        .  447 


COSMETIC  RHINOPLASTY 

469  a,  469  b. — Monk  method  of  correction  of  angular  nose      .        .        .  450 

470,  471,  472. — Median  nasal  incision  for  angular  nose     ....  4.">1 

473,  474. — Kolle  method  of  lateral  incision  for  angular  nose    .        .        .  452 

475,  476.— Kolle  chisel  set 453 

477. — Kolle  metal  mallet 453 

478,  479. — Kolle  method  of  correction  of  retrousse'  nose    ....  454 

480,  481. — Kolle  method  of  correction  of  broad  lobule      ....  456 


LIST    OF    ILLUSTRATIONS  xxi 

PIG.  PAGE 

482,  483. — Kolle  method  of  correction  of  elongated  lobule  .  .  .  458 
484. — Kolle  method  of  correction  of  elongated  lobule  and  base  of  nose 

after  excision 460 

485. — Kolle  method  of  correction  of  elongated  lobule  base  of  also  and 

lobule 460 

486,  487.— Kolle  plaster  cast  of  lobule  operation 461 

488,  489. — Kolle  plaster  cast  of  lobule  operation 462 

490,  491.— Kolle  plaster  cast  of  lobule  operation 463 

492,493. — Kolle  plaster  cast  of  lobule  operation 464 

494,  495. — Gensoul  method  of  correcting  broad  nasal  base  .  .  .  465 

496,  497. — -Kolle  method  of  correction  of  broad  nasal  base  .  .  .  465 

498,  499. — Linhardt  method  of  reduction  of  thickened  alae  .  .  .  466 

500,  501. — Dieffenbach  method  of  reduction  of  thickened  nose  .  .  467 

ELECTROLYSIS  IN  DERMATOLOGY 

502.— Electric  wet  cell 470 

503. — Series  connection  of  cells 472 

504. — Shunt  rheostat  connection 473 

505.— Cell  selector 474 

506. — Cell  selector  and  battery  connection 474 

507. — Milliamperemeter 475 

508. — Direct  current  wall  plate 475 

509. — Wall-plate  connections 475 

510  a. — Portable  wet  cell  apparatus 476 

510  b. — Portable  dry  cell  apparatus 477 

511. — Sponge  electrode -.        .        .  478 

512. — Arm  electrode 478 

513,  514.— Electrolytic  needle  holders 479 

515. — Interrupting  current  needle  holder 479 

516. — Needle  holder  with  magnifying  glass 479 

517. — Epilating  forceps 481 

518. — Electrolysis  method  for  destroying  growths 483 

519. — Multiple  needle  electrode 484 

520. — Kolle  electric  apparatus  for  tattooing  scars 487 

CASE  RECORDING  METHODS 

521.— Nose  stencil 492 

522. — Method  of  making  nose  plaster  cast 494 


PLASTIC   AND   COSMETIC   SURGERY 


CHAPTER   I 

ITTSTOKICAL 

IT  seems  almost  incredible  that  at  this  late  day  so 
little  is  generally  known  to  the  surgical  profession  of  the 
beautiful  and  practical,  not  to  say  grateful,  art  of  plastic 
or  restorative  surgery,  successfully  practiced  even  by 
the  ancients. 

The  progress  of  the  art  has  been  much  interrupted. 
It  is  only  the  later  methods  of  antisepsis,  which  have  so 
greatly  added  to  general  surgery,  that  have  placed  it 
firmly  upon  the  basis  of  a  distinct  and  separate  art  in 
surgical  science. 

To  Aulus  Cornelius  Celsus,  a  Latin  physician  and 
philosopher,  supposed  to  have  lived  in  the  time  of  Augus- 
tus, we  owe  the  first  authentic  principles  of  the  science. 
He  was  a  most  prolific  writer  and  an  urgent  worker. 
After  having  introduced  the  Hippocratic  system  to  the 
Eomans  he  became  known  as  the  Roman  Hippocrates. 
His  best-known  work  handed  down  to  us  is  the  "  De  Medi- 
cina,"  the  first  edition  of  which,  divided  into  eight  books, 
appeared  in  Florence  in  1478.  The  seventh  and  eighth 
volumes,  designated  the  "  Surgical  Bible,"  contain  much 
valuable  data  in  reference  to  opinions  and  observations 
of  the  Alexandrian  School  of  Medicine. 

In  considering  plastic  operations  about  the  face 
(Curta  in  auribus,  labrisque  ac  naribus)  he  writes, 
"  Ratio  curationis  ejus  modi  est ;  id  quod  curtatum  est, 
in  quadratum  redigere ;  ab  interoribus  ejus  angulis  lineas 
transversas  incidere,  quae  citeriorem  partem  ab  ulteriore 

2  1 


ex  toto  diducant ;  deinda  ea  quae  resolvimus,  in  uimm  ad- 
ducere.  Si  non  satis  junguntur,  ultra  lineas,  quas  ante 
fecimus,  alias  dua  lunatas  et  ad  plagam  conversas  immit- 
tere,  quibus  sumina  tantum  cutis  diducatur,  sic  enim  fit,  ut 
facilius  quod  adducitur,  segui  possit,  quod  non  vi  cogen- 
dum  est,  sed  ita  adducendum  ut  ex  f acili  subsequatur ;  et 
dimissum  non  multum  recedat." 

Centuries  elapsed  before  a  clear  understanding  of  the 
above  was  deduced.  Several  analyses  have  been  ad- 
vanced, those  of  0.  Weber  and  Malgaigne  being  the  most 
generally  accepted. 

As  shown  in  Fig.  1  the  method  advanced  is  one  for 
the  restoration  or  repair  of  an  irregular  defect  about  the 
face  in  which  two  transverse  incisions  forming  angular 
skin  flaps,  dissected  from  the  underlying  tissue,  are  ad- 
vanced, joining  the  denuded  free  ends. 

Should  there  be  a  lack  of  tissue  to  accomplish  perfect 
coaptation  a  semilunar  incision  beyond  either  outer  bor- 
der is  added,  as  shown  in  Fig.  2>  which  permits  of  greater 
traction,  leaving  two  small  quatrespheral  areas  to  heal 
over  by  granulation : 


FIG.  1. — CELSTTS  INCISION  FOR 
RESTORATION  OF  DEFECT. 


FIG.  2. — CELSTTS  INCISION  TO 
RELIEVE  TENSION. 


This  is  the  oldest  known  reference  to  plastic  surgery  of 
times  remote. 

From  the  Orient,  however,  Susrata  in  his  Ayur-Veda, 
the  exact  period  of  which  is  unknown,  discloses  the  use 
of  rhinoplastic  methods. 


For  centuries  following,  and  throughout  the  middle 
ages,  the  art  seems  to  have  waned  and  remained  practi- 
cally unknown,  as  far  as  is  shown  in  the  literature  of 
that  period. 

A  revivalist  first  appeared  about  the  middle  of  the 
fifteenth  century  in  the  person  of  Branca,  of  Catania,  a 
Sicilian  surgeon,  who  about  1442  established  a  reputation 
of  building  up  noses  from  the  skin  of  the  face  (exore). 
His  son  Antonius  enlarged  upon  his  methods  and  is  said 
to  have  utilized  the  integument  of  the  arm  to  accomplish 
the  same  result,  thus  overcoming  the  extensive  scarring 
of  the  face  following  the  elder's  mode.  He  seems  to  have 
been  the  first  authority  employing  the  so-called  Italian 
rhinoplastic  method.  He  is  also  known  to  have  ven- 
tured, more  or  less,  successfully  in  operations  about  the 
lips  and  ears. 

Balthazar  Pavoni  and  Mongitore  repeated  these  meth- 
ods of  operative  procedure  with  more  or  less  success  and 
the  brothers  Bojanis  acquired  great  celebrity  at  Naples 
in  the  art  of  remodeling  noses. 

Vincent  Vianeo  followed  the  work  of  the  above. 

But,  somehow,  the  heroic  efforts  of  these  men 
dropped  so  much  into  oblivion  that  Fabricius  ab  Aqua- 
pende,  in  writing  of  the  rhinoplastic  work  of  the  broth- 
ers Bojani,  of  Calabria,  says :  "  Primi  qui  modum  repar- 
andi  nasum  coluere,  fuerunt  calabri;  deinde  devenit  ad 
medicos  Bononienses." 

That  Germany  was  interested  at  an  early  date  is 
shown  in  the  admirable  work  of  a  chevalier  of  the  Teu- 
tonic Order,  Brother  Heinrich  Von  Pfohlspundt,  who 
wrote  a  book  on  the  subject  entitled  "  Buch  der  Brundth 
Ertznei,"  with  a  subtitle,  "  Eynem  eine  nawe  nasse  zu 
mache."  His  volume  appeared  in  1460,  about  the  time  of 
Antonio  Branca,  of  whose  methods  he  was  ignorant, 
claiming  to  have  learned  the  art  from  an  Italian  who 
succored  many  by  his  skill. 

Between  the  years  of  1546  and  1599  Kaspar  Taglia- 


4    PLASTIC  AND  COSMETIC  SURGERY 

cozzi,  Professor  at  Bologna,  followed  the  art  of  rhino- 
plasty.  His  pupils  published  a  book  at  Venice,  describ- 
ing his  work  in  1597,  entitled  "  De  Corturum  chirurgia 
per  insitionem,"  which  established  the  first  authentic 
volume  in  restorative  surgery.  His  operation  for  restor- 
ing the  entire  nose  from  a  double  pedicle  flap  taken  from 
the  arm  was  declared  famous  and  the  operation  he  then 
advocated  still  bears  his  name. 

The  great  Ambroise  Pare  knew  little  of  rhinoplasty 
except  what  he  learned  from  hearsay.  As  an  instance, 
he  relates  in  1575  that  "A  gentleman  named  Cadet  de 
Saint-Thoan,  who  had  lost  his  nose,  for  a  long  time  wore 
a  nose  made  of  silver  and  while  being  much  hurt  by  the 
criticisms  and  taunts  of  his  acquaintances  heard  of  a 
master  in  Italy  who  restored  noses.  He  went  there  and 
had  his  facial  organ  restored,  and  returned  to  the  great 
surprise  of  his  friends,  who  marveled  at  the  change  in 
their  formerly  silver-nosed  friend." 

Now  again  came  a  century  of  forgetfulness,  the  scien- 
tific world  taking  no  cognizance  of  the  work  done  until, 
suddenly,  in  1794,  a  message  came  from  Poonah,  India, 
to  the  effect  that  an  East  Indian  peasant  named  Cowas- 
jee,  a  cowherd  following  the  English  army,  was  captured 
by  Tippo  Sahib,  who  ordered  the  prisoner's  nose  to  be 
amputated.  His  wounds  were  dressed  and  healed  by 
English  surgeons.  Shortly  after  this  the  victim  of  this 
odd  mode  of  punishment  was  befriended  by  the  Koomas, 
a  colony  of  potters,  or,  as  others  claim,  a  religious  sect, 
who  knew  how  to  restore  the  nose  by  means  of  a  flap 
taken  from  the  forehead.  They  operated  on  him  and  re- 
stored his  nose  much  to  the  surprise  of  Pennant,  who 
reported  the  case  in  England. 

Shortly  following  this,  and  in  the  same  year,  cases  of 
similar  nature  are  described  in  the  Gentlemen's  Maga- 
zine (England),  and  Pennant's  "Views  of  Hindoostan." 

In  1811  Lynn  successfully  accomplished  the  operation 
in  a  case  in  England,  and  in  1814  Carpue  published  his 


results  in  two  cases  successfully  operated  by  him  by  the 
so-called  Hindoo  method. 

France  now  took  up  the  art  of  rhinoplasty.  Delpech 
introduced  a  modification  of  the  method  of  the  Koomas 
in  1820,  while  Lisfranc  performed  the  first  operation  of 
this  nature  in  Paris  in  1826. 

In  1816  Graefe,  of  Germany,  took  up  the  work  of  Tag- 
liacozzi  but  modified  his  method  by  diminishing  the  num- 
ber of  operations. 

Biinger,  of  Marburg,  thereupon,  in  1823,  successfully 
made  a  man's  nose  by  taking  the  necessary  tegument 
from  the  patient's  thigh. 

A  still  later  modification  in  the  art  of  rhinoplasty 
was  that  of  Larrey,  who  in  1830  overcame  a  large  loss 
about  the  lobule  of  the  nose  by  taking  the  flaps  to  restore 
the  same  from  the  cheeks. 

Among  the  better  advocates  of  reparative  chirurgery 
were  Dieffenbach,  v.  Langenbeck,  Bicard,  v.  Graefe 
(1816),  Alliot,  Blandin,  Zeis,  Serre,  and  Joberi,  while 
Thomas  D.  Mutter,  in  1831,  published  the  results  he  ob- 
tained in  America — his  co-workers  being  "Warren  and 
Pancoast. 

Although  Le  Monier,  a  French  dentist,  as  early  as  1764 
originally  proposed  closure  of  the  cleft  in  the  soft  palate, 
no  one  attempted  to  carry  out  his  suggestion  until  in 
1819  the  elder  Boux,  of  Paris,  performed  the  operation. 
The  following  year  Warren,  of  Boston,  independently  de- 
cided upon  and  successfully  did  an  improved  operation 
to  the  same  end. 

During  the  years  1865-70  Joseph  Lister  distinguished 
himself  in  the  discovery  and  meritorious  employment  of 
carbolic  acid  as  a  means  of  destroying,  or  at  least  arrest- 
ing, infectious  germ  life,  the  principle  of  which,  now  so 
fully  developed,  has  advanced  the  obtainable  surgical  pos- 
sibilities inestimably. 

The  credit  of  first  collecting  data  of  plastic  operations 
belongs  to  Szymanowski,  of  Bussia,  In  his  magnificent 


6    PLASTIC  AND  COSMETIC  SURGERY 

volume  of  surgery  (1867),  he  embodies  a  somewhat  thor- 
ough treatise  on  restorative  surgery,  leaving  the  subject 
to  be  treated  more  fully  and  independently,  as  it  should 
be,  to  some  other  enthusiastic  surgeon  specialist.  His 
work  is  the  result  of  careful  study  of  such  operations  on 
the  cadaver,  a  method  much  to  be  recommended  to  the 
prospective  or  operating  plastic  surgeon. 

Several  years  later,  1871,  Reverdin  added  a  valuable 
method  to  the  still  incomplete  art,  by  introducing  the 
now  well-known  circular  epidermal  skin  grafts  for  cov- 
ering granulating  surfaces.  Thiersch  improved  this 
method  in  1886  by  showing  that  comparatively  large 
pieces  of  skin  could  be  transplanted.  Wolfe,  of  Glasgow, 
had  also  been  successful  in  utilizing  fairly  large  skin 
grafts. 

Krause,  however,  improved  upon  all  of  these  methods 
by  transplanting  large  flaps  of  skin  without  detaching 
the  subcutaneous  tissue,  a  procedure  which  causes  more 
or  less  injury  to  the  graft  in  other  methods,  and  by  his 
method  overcoming  the  subsequent  contraction,  hereto- 
fore a  bad  feature  when  the  skin-grafted  area  had 
healed. 

"  The  results  of  most  plastic  operations  have  been  as 
satisfactory  as  the  most  sanguine  could  hope  for  or  the 
most  critical  expect,"  says  John  Eric  Erichsen. 

Many  important  additions  have  been  made  in  the  past 
few  years — the  outcome  of  untiring  attempt  and  skill. 
Czerny  replaces  part  of  an  amputated  breast  with  a  fatty 
tumor  taken  from  the  region  of  the  thigh.  Gliick  suc- 
cessfully repairs  a  defect  in  the  carotid  artery  with  the 
aid  of  a  piece  of  the  jugular  vein.  Gliick,  Helferich,  and 
others  have  advocated  implanting  muscular  tissue  taken 
from  the  dog  into  muscular  deficiencies  in  the  human,  due 
to  whatever  cause. 

The  transplantation  of  a  zooneural  section  into  a  de- 
fect of  a  nerve  in  the  human  was  successfully  accom- 
plished by  Phillippeaux  and  Vulpian. 


HISTORICAL  7 

Gliick,  who  later  restored  a  sciatic  nerve  in  a  rabbit 
by  the  transplantation  of  the  same  nerve  taken  from  a 
hen,  went  so  far  as  to  restore  a  5-cm.  defect  of  the 
radial  nerve  of  a  patient  by  the  employment  of  a  bundle 
of  catgut  fibers,  fully  establishing  the  function  of  the 
nerve  within  a  year's  time. 

Guthrie  has  successfully  replaced  the  organs  and 
limbs  of  animals  and  has  actually  transplanted  the  heads 
of  two  dogs. 

The  transplantation  of  a  toe,  to  make  up  a  part 
of  a  lost  finger,  is  proposed  by  Nicoladoni.  Van  Lair 
hints  at  the  possibility  of  removing  a  part  or  a  whole 
organ  immediately  before  death  to  repair  other  living 
organs. 

Von  Hippel  has  successfully  implanted  a  zoocorneal 
graft  from  a  rabbit  upon  the  human  eye,  and  Copeland 
has  taken  the  corneal  graft  from  one  human  and  trans- 
planted it  upon  the  cornea  of  another  to  overcome 
opacity. 

The  transplantation  of  pieces  of  bone  to  overcome  a 
defect  of  like  tissue  has  been  fully  investigated  by  Oilier, 
v.  Bergman,  J.  Wolff,  MacEwen,  Jakimowitsch,  Ried- 
inger,  and  others.  They  discovered  that  a  graft  of  bone, 
with  or  without  its  periosteum,  can  be  made  to  heal  into 
a  defect  when  strict  antisepsis  is  maintained. 

Von  Nussbaum  was  the  first  to  introduce  the  closing 
of  an  osseous  defect  by  the  use  of  a  pedunculated  flap  of 
periosteum. 

Poncet  and  Oilier  employed  small  tubular  sections  of 
bone,  while  Senn  has  obtained  excellent  results  from  the 
use  of  chips  of  aseptic  decalcified  bone. 

Hahn  succeeded  in  implanting  the  fibula  into  a  defect 
of  the  tibia. 

On  the  other  hand,  cavities  in  the  bones  have  been 
successfully  filled  by  Dreesmann  and  Heydenreich  with 
a  paste  of  plaster  made  with  a  five-per-cent  carbolic-acid 
solution,  and  at  a  later  period  by  the  employment  of 


8    PLASTIC  AND  COSMETIC  SURGERY 

paraffin  (Gersuny)  and  iodoform  wax,  as  advocated  by 
Mosetig-Moorhof. 

The  thyroid  glands  taken  from  the  sheep,  it  is 
claimed,  have  been  successfully  implanted  in  the  abdo- 
men of  individuals  whose  thyroid  glands  had  been  lost 
by  disease  or  otherwise. 

Protheses  of  celluloid  compound  or  gutta-percha  and 
painted  to  resemble  the  nose  or  ear  have  been  introduced 
with  grateful  result.  Metal  and  glass  forms  have  been 
used  to  replace  extirpated  testicles  or  to  take  the  place 
of  the  vitreous  humor  of  the  eye  (Mule). 

Sunken  noses  have  been  raised  with  metal  wire,  metal 
plates,  amber,  and  caoutchouc.  Metal  plates  have  been 
skillfully  fitted  into  the  broken  bony  vault  of  the  cranium. 

Lastly  comes  Gersuny's  most  valuable  method  of  in- 
jecting paraffin  compounds  subcutaneously  for  the  res- 
toration of  the  contour  of  facial  surfaces  and  limbs, 
which  is  rapidly  taking  the  place  of  extensive  plastic 
transplantory  and  the  much-objected-to  metal  and  bone- 
plate  operations  for  building  up  depressed  noses  and 
other  abnormal  cavities. 

And  the  end  of  possibilities  is  not  yet  reached.  The 
successful  plastic  surgeon  has  become  an  imitator  of 
nature's  beauty  to-day. 

His  skill  permits  of  many  almost  unbelievable  correc- 
tions of  defects  that  would  otherwise  evoke  the  pity  and 
too  often  the  aversion  of  the  onlooker,  especially  if  these 
occur  in  the  faces  of  those  that  have  become  marred 
in  birth  or  age,  by  accident  or  disease.  Withal,  it  is  a 
noble,  generous  art,  worthy  of  far  more  extensive  use 
than  it  now  enjoys. 

The  above  fragmentary  references  include  a  number 
of  plastic  possibilities.  They  are  introduced  only  in  the 
sense  of  general  interest  to  the  cosmetic  surgeon,  the 
special  and  detailed  subject  matter  herein  given  under 
the  various  divisions  have  to  do  only  with  plastic  and 
cosmetic  operations  about  the  face. 


CHAPTEE   II 

REQUIREMENTS    FOR    OPERATING 

THE   OPERATING  ROOM 

THE  ideal  operating  room  for  the  plastic  surgeon  need 
not  necessarily  be  large,  since  it  requires  less  work  to 
render  it  aseptic.  Furniture  and  possibly  amphitheater 
accommodation  are  always  a  means  of  infection  unless 
scrupulously  cleansed,  a  task  of  time,  difficult  at  best. 

The  room  should  be  provided  with  large  windows, 
with  facilities  for  the  introduction  of  the  air  from  with- 
out. Two  doors,  and  those  well  fitted,  are  all  the  room 
should  have — but  one  being  used,  if  possible. 

The  Walls. — The  walls  should  be  of  plaster,  smoothly 
laid  and  well  painted,  so  that  they  may  be  readily  washed 
down  with  antiseptic  solutions — a  daily  morning  rule. 
Glass  or  tiled  walls  are  much  used  now  and  add  consider- 
ably to  the  appearance  and  safety  of  the  room,  as  plaster 
in  time  will  crack,  while  the  paint,  owing  to  the  heat  of 
sterilizers  or  steam,  often  creeps  and  blisters,  exposing 
an  absorbing  surface  which  readily  wears  down,  exposing 
parts  inaccessible  for  even  acute  cleanliness. 

The  Floors. — The  floors  of  these  rooms  are  now  usually 
laid  with  tile  mosaic  or  marble  or  a  composition  resem- 
bling linoleum.  The  base  should  be  curved  and  all  cor- 
ners sloped  off  to  improve  drainage  and  to  keep  off  dust 
and  dirt. 

Skylight. — A  skylight  of  metal  and  glass  is  a  valuable 
accessory.  It  should  be  fixed  or  never  permitted  to  be 
opened  during  an  operation. 

9 


10       PLASTIC   AND    COSMETIC    SURGEKY 

Disinfection. — Spraying  the  room  with  an  antiseptic  is 
hardly  necessary,  since  all  germ  life  descends  to  the  floor 
and  can  best  be  removed  by  washing  with  a  1-1000  bi- 
chlorid  solution. 

Should  it  be  necessary  to  perform  an  unusually  exten- 
sive operation  in  a  private  house,  the  room  must  be 
cleared  of  all  furniture,  pictures,  drapery,  and  carpet. 
After  plugging  up  the  crevices  in  the  windows  and 
doors  it  should  be  well  fumigated  either  with  sulphur 
candles,  as  now  commonly  furnished,  or,  better,  with  for- 
maldehyd. 

The  superiority  of  formaldehyd  as  a  disinfecting 
agent  is  now  well  established.  An  illustration  of  an  ap- 
paratus, largely  doing  away  with  the  difficulties  and 
dangers  encountered  in  the  use  of  the  older  and  ordinary 
styles  of  the  pressure  or  nonpressure  type,  is  shown  in 
Fig.  3.  The  main  difficulty  with  these  has  always  been 
their  almost  inacessibility  for  cleansing  purposes,  and  in 
such  where  this  is  not  the  case,  the  size  of  the  aperture 
has  been  made  so  small  that  the  inside  could  not  be 
reached.  In  the  pressure  apparatus  the  tops  are  bolted 
on,  making  them  exceedingly  difficult  to  remove,  with  the 
result  that  the  necessary  cleaning  was  not  properly  at- 
tended to.  The  corrosive  action  of  formaldehyd  gas  is 
such  that  under  these  conditions  any  apparatus  would 
soon  become  useless. 

In  the  type  .shown  a  single  clamp  arrangement  is 
used  (a).  By  the  turning  of  the  hand  screw  (b)  two 
planed  metal  faces  (the  upper  surface  of  the  boiler  and 
under  surface  of  the  cover)  are  brought  together  and 
sealed.  When  the  cover  (c)  is  removed  the  entire  inside 
of  the  boiler  is  in  sight  and  can  be  thoroughly  cleansed, 
which  should  be  done  each  time  the  apparatus  is  used. 
The  pipes  through  which  the  formaldehyd  gas  passes 
after  generation  are  arranged  so  that  they  can  be  taken 
off  and  cleaned. 

The  gas  is  generated  in  the  boiler  (d)  and  passes  out 


REQUIREMENTS   FOE   OPERATING         11 

from  the  top,  down  through  the  pipe  (e),  and  from  thence 
through  a  series  of  pipes  (/)  underneath  the  boiler,  which 
are  subjected  to  direct  heat  from  the  lamp  (g).  By  this 


FlG.  3. FORMALDEHYD    DISINFECTING    APPPARATUS. 

means  the  gas  becomes  superheated,  the  polymerization 
of  the  formaldehyd  is  almost  entirely  prevented,  and  a 
dry  gas  is  insured  and  given  off  at  the  pipe  (h). 


12   PLASTIC  AND  COSMETIC  SURGERY 

The  room  should  be  left  closed  overnight  and  thor- 
oughly aired  thereafter.  The  bare  floor  must  then  be 
scrubbed  with  hot  water  and  soda  and  flushed  with  a 
three-per-cent  carbolic-acid  solution. 

As  little  furniture  as  possible  should  be  found  in  an 
operating  room,  and  this  preferably  of  undecorated 
enameled  iron. 


FIG.  4. — INSTRUMENT  CABINET. 


Instrument  Cabinet. — For  the  instruments  and  dressings 
there  should  be  a  dust-proof  cabinet  of  iron  and  glass, 
such  as  is  shown  in  Fig.  4, 


REQUIREMENTS    FOR   OPERATING          13 

Operating  Table. — The  operating  table  should  be  of  like 
construction  and  as  plain  as  possible.  Its  top  can  be 
padded  with  sterilized  felt,  protected  from  moisture  by 


FIG.  5. — OPERATING  TABLE. 

rubber  sheets.  A  surgical  chair  of  plain  construction 
might  suffice,  inasmuch  as  most  plastic  operations  cover 
but  a  small  area  and  are  usually  about  the  head  and  often 
performed  under  local  anesthesia.  A  chair  with  head  rest 
is  much  more  comfortable,  adding  much  to  the  moral  and 
physical  comfort  of  the  then  conscious  patient.  A  very 
desirable  chair  is  shown  in  Fig.  5. 

Instrument  Table. — An  instrument  table,  such  as  is 
shown  in  the  next  illustration,  is  quite  necessary,  upon 
which  dressings  and  instruments  are  laid  during  opera- 


14       PLASTIC   AND   COSMETIC    SURGERY 

tion.    In  this  the  frame  is  of  white  enameled  iron  and  the 
top  and  shelf  of  plate  glass. 


FIQ.  6. — INSTRUMENT  TABLE. 


Irrigator. — An  irrigator  is  often  of  service,  especially 
in  washing  out  the  fine  pieces  of  bone  resulting  from 
chiseling  or  drilling.  In  skin-grafting  it  may  be  used 
with  sterilized  three-per-cent  salt  solution  as  described 
later.  The  best  irrigators  are  those  of  germ-proof  or 
ground-glass  stopper  type.  They  are  suspended  from 
the  wall  by  means  of  an  iron  bracket  or  pulley  service 
or  placed  upon  a  movable  enameled  stand  as  shown  in 
Fig.  7. 

Irritating  antiseptic  solutions  are  to  be  avoided,  their 
especial  indication  will  be  found  under  antiseptic  care  of 
wounds. 

CARE   OF  INSTRUMENTS 

All  instruments  should  be  of  modern  make,  devoid  of 
clefts  or  grooves,  and  having  separating  locks  when  pos- 
sible. Wooden  or  ivory  handles  should  be  entirely  dis- 


REQUIREMENTS    FOR    OPERATING          15 


carded.  They  should  first  be  rendered  free  of  dirt  or 
dried  blood  by  scrubbing  briskly  with  a  stiff  nailbrush 
and  hot  water;  then  dried  and 
placed  in  the  sterilizer.  The  im- 
mersed instruments  are  boiled  for 
five  or  ten  minutes.  There  are 
many  of  such  sterilizing  appa- 
ratuses to  be  obtained,  all  made 
on  the  same  plan,  however,  and 
consist  of  a  copper  or  brass 
box  and  cover  well  nickel  plated. 
Folding  legs  are  placed  beneath. 
A  perforated  tray  is  placed 
within  for  the  immersion  of  in- 
struments. An  alcohol  lamp 
with  asbestos  wick  furnishes  the 
heat. 

One  per  cent  of  carbonate  of 
soda  added  to  the  water  prevents 
them  from  rusting.  The  simple 
subjection  of  instruments  to  car- 
bolic-acid solutions  or  antiseptics 
of  like  nature  is  useless.  (Gart- 
ner, Kiimmel,  Gutch,  Redard,  and 
Davidsohn.) 

From  the  sterilizer  the  instru- 
ments are  placed  in  a  glass  tray 
containing  a  one-per-cent  lysol 
solution.  Knives,  needles,  and 
scissors  should  be  immersed  in  a 
tray  with  alcohol,  as  a  great  num- 
ber of  antiseptics  destroy  their 
cutting  edges.  Glass  or  porcelain 
trays  are  best  for  this  purpose. 
A  sterilized  towel  being  placed 
in  the  bottom  of  each  for  the  bet- 
ter placing  of  instruments.  Fia.  7.— IKRIGATOB. 


16       PLASTIC   AND   COSMETIC    SURGERY 

After  operation  all  instruments  should  again  be 
scrubbed  with  soap  and  hot  water,  immersed  a  moment  in 
boiling  water  or  a  jet  of  live  steam,  dried  with  an  aseptic 
cloth,  and  returned  to  the  case. 


FIG.  8. — INSTRUMENT  STERILIZER. 

A  very  effectual  means  of  rendering  instruments 
sterile  is  to  place  them  in  a  metal  box  and  bake  them  in 
the  ordinary  oven  (200°  F.)  for  one  hour. 

To  preserve  needles  Dawbarn  advises  keeping  them 
in  a  saturated  solution  of  washing  soda.  Albolene  has 
an  unpleasant  oiliness,  but  is  otherwise  good.  Calcium 
chlorid  in  absolute  alcohol  is  efficacious,  but  expensive. 
All  rust  accumulating  on  instruments  must  be  carefully 
removed  with  fine  emery  cloth ;  this,  however,  is  unneces- 
sary if  the  soda  solution  is  used  as  previously  mentioned. 
It  is  well  to  occasionally  dip  the  instruments  (holding 
them  with  an  artery  forceps)  into  boiling  water  as  they 
are  used  during  operation. 

PREPARATION   OF  THE    SURGEON  AND  ASSISTANTS 
CARE  OP  THE  HANDS 

The  hands  of  the  surgeon  and  his  assistants  must 
always  be  thoroughly  prepared  before  operation  or 
dressing  a  wound.  The  mere  immersion  of  the  hands 
into  an  antiseptic  solution  is  not  sufficient  to  remove 


REQUIREMENTS   FOR   OPERATING          17 

germ  life.  The  oily  secretions  of  the  skin  and  its  folds, 
as  well  as  the  cleft  about  the  nails  and  the  nails  them- 
selves, are  common  carriers  of  infection  and  are  cleansed 
only  by  the  vigorous  method  of  scrubbing  with  soap  and 
water  and  then  rendered  aseptic  by  the  use  of  proper 
media. 

The  aseptic  hospital  washstand,  as  shown  in  Fig.  9, 
will  be  found  an  ideal  piece  of  furniture ;  it  has  'a  frame 
constructed  of  wrought  iron,  white  enameled.  The  top 
is  of  one-inch  polished  plate  glass,  with  two  twelve-inch 
holes. 

The  entire  stand  can  be  moved  away  from  the  wall,  to 
permit  of  thorough  cleaning  of  basins,  supply  pipes,  etc. 


FIG.  9. — ASEPTIC  WASHSTAND. 


The  basins  are  the  best  annealed  glass,  and  are  supported 
by  nickel-plated  traps,  with  connections  for  vent  pipes. 
The  water  supply  is  controlled  by  foot  valves,  which  en- 
able the  operator  to  draw  either  cold,  medium,  or  hot 
water  at  will.  The  waste  is  also  controlled  by  a  foot 
valve,  as  shown. 

3 


18       PLASTIC   AND    COSMETIC    SURGERY 

The  systematic  law  of  cleansing  the  hands  should  be 
insisted  upon  at  all  times.  Rules  for  the  method  followed 
might  be  displayed  in  abbreviated  form  in  the  operating 
room  by  glass  or  enameled  signs  hung  on  the  wall  over 
the  basin  and  reading  as  follows : 


YOUR   HANDS 
1.     Clean  nails. 
II.     Scrub  with  very  hot  water  and  soap  for  five  minutes. 

III.  Wipe  in  sterile  towel. 

IV.  Brush  with  eighty  per  cent  alcohol. 
V.     Dip  into  antiseptic  solution. 


Green  soap  is  commonly  used  and  is  to  be  preferred  to 
powdered  or  cake  soap.  The  powder  cakes  and  clogs  the 
container  in  damp  weather,  while  the  latter  collects  im- 
purities from  the  air.  Synol  soap,  also  liquid,  is  perhaps 
the  most  ideal,  a  two  per  cent  solution  of  which  forms  an 
excellent  lavage  for  cleaning  instruments,  as  well  as 
washing  down  furniture  in  the  operating  room. 

The  brushes  to  be  used  are  of  the  common  wooden- 
back,  hard-bristle  make,  which  can  be  boiled  without  in- 
jury. There  should  be  several  of  these,  marked  on  their 
backs  as  desired,  so  that  one  brush  can  be  used  for  the 
one  purpose  only.  In  cleansing  the  hands,  the  forearms, 
and  even  the  elbows,  should  be  similarly  treated.  After 
scrubbing  with  soap,  as  directed,  they  are  to  be  rinsed, 
dried  with  a  sterilized  towel,  again  scrubbed  with  alcohol, 
and  then  dipped  or  flushed  with  a  bichlorid  solution. 

GOWNS 

No  woolen  garments  should  be  allowed  to  come  in  con- 
tact with  the  site  of  the  operation,  nor  is  it  well  to  allow 
such  material  in  the  operating  room  while  working. 

Freshly  laundered  linen  gowns  of  Von  Bergman's 
pattern,  reaching  to  the  shoes,  should  be  worn.  They 


19 


should  contain  half  sleeves  and  be  buttoned  on  the  back. 
See  Fig.  10.  These  may  be  sterilized  in  the  steam  ster- 
ilizer or  washed  in  one-per-cent  soda  solution.  When 
soiled  or  blood-stained  they  should  be  relaundered. 


FIG.  10. — VON  BERGMAN  OPERATING 
GOWN. 


FIG.  11. — TRIFFE  RUBBER  APRON. 


The  operator  may  substitute  the  gown  with  a  rubber 
apron  of  the  Triffe  pattern,  reaching  as  high  as  the  col- 
lar, but  continuous  washing  quickly  ruins  them.  See 
Fig.  11. 

PREPARING  THE  PATIENT 

GENERAL  PREPARATION 

The  patient  for  all  plastic  operations  should  be  care- 
fully examined  as  to  general  health  and  past  history. 
His  healing  powers  should  be  at  their  best,  as  much  de- 
pends on  primary  union.  If  he  presents  a  syphilitic  his- 


tory,  it  is  well  to  place  him  under  treatment,  for  a  time, 
at  least,  before  an  operation  is  undertaken.  The  bowels 
should  be  regular.  Sulphate  of  magnesium  should  be 
given  each  morning,  before  breakfast,  for  at  least  two 
days  prior  to  operating,  while  his  general  condition  may 
be  improved  by  the  employment  of  bitter  and  alterative 
tonics.  Nux  vomica  with  tinct.  cinchonas  com.,  associ- 
ated with  essence  of  pepsin  aromat.,  or  lactopeptone, 
are  very  useful.  This  treatment  is  also  carried  on  for 
several  days,  post  operatio. 

The  success  of  an  operation  depends,  first,  upon  the 
selection  of  the  case ;  second,  the  selection  of  the  method 
employed,  and,  third,  upon  the  hygiene  under  which  the 
patient  undergoes  convalescence.  The  patient  must  be 
given  to  understand,  in  many  cases,  that  it  is  often  neces- 
sary to  reoperate,  even  to  the  extent  of  seven  or  eight 
operations,  to  bring  about  the  desired  result.  The  first 
result  obtained  with  many  cosmetic  operations  is  not  at 
all  gratifying  to  the  patient,  and  unless  this  is  explained 
to  him  beforehand  he  may  become  discouraged  await- 
ing the  next  operation  and  disappear,  thus  losing  the 
opportunity  of  being  pleased  finally,  while  the  surgeon 
is  misunderstood  and  underestimated  by  narrow-minded 
judges  and  the  ever-willing  friendly  advisers  and  critics 
— a  consummation  much  to  be  avoided. 

PREPARATION  OF  THE  OPERATIVE  FIELD 

The  part  to  be  operated  upon  should  first  be  closely 
shaven.  The  oily  secretions  of  the  area  are  next  rubbed 
off  with  an  absorbent  cotton  sponge  saturated  with  al- 
cohol or  ether.  Next,  the  skin  is  washed  with  hot  water 
and  soap  or  three-per-cent  synol  suds,  then  rinsed,  and 
finally  rendered  aseptic  with  a  bichlorid  solution. 

If  the  operation  is  to  be  done  about  the  face  a  rubber 
cap  is  so  adjusted  as  to  cover  the  hair.  If  this  is  not 
obtainable  sterilized  bandages  can  be  employed. 


REQUIREMENTS    FOR    OPERATING          21 

In  operations  about  mucous  membranes,  as  in  the 
nose  and  mouth,  the  parts  must  be  cleaned  at  short  inter- 
vals with  a  solution  of  permanganate  of  potash  or  boric 
acid.  The  teeth  must  be  cleansed  with  antiseptic  soap, 
tartar  is  scraped  off,  and  the  mouth  rinsed  with  a  proper 
disinfectant.  The  corrosive  sublimate,  or  carbolated 
solutions,  owing  to  their  toxic  qualities,  cannot  be  used. 
The  preparation  of  wounds  for  reoperation,  or  where  an 
operation  is  secondary  to  injury,  is  referred  to  later. 

All  clothing  about  the  site  of  operation  should  be  re- 
moved and  rubber  cloth  placed  to  surround  the  field  and 
cover  the  clothing.  This  should  be  covered  aga*in  with 
sterilized  towels.  Everything  that  touches  the  patient 
after  this  has  been  done  should  be  aseptic ;  indeed,  hands 
employed  during  operation  must  be  immersed  from  time 
to  time  in  1-500  bichlorid  solution,  and  allowed  to  remain 
wet. 


CHAPTER   III 
REQUIREMENTS   DURING   OPERATION 

SPONGES  AND   SPONGING 

NATURAL  or  sea  sponges  are  now  little  used  in  sur- 
gery, owing  to  their  peculiar  cellular  construction.  They 
invite  and  readily  retain  spores  and  germs,  are  difficult 
to  clean,  and  require  almost  constant  attention  to  be 
at  all  safe. 

Many  methods  for  rendering  these  sponges  aseptic 
have  been  proposed,  but  at  best  the  life  of  such  a  sponge 
is  short  and  hardly  pays  for  the  labor  and  time  expended. 
The  absorbing  power  of  a  sponge  is,  of  course,  its  essen- 
tial quality.  For  plastic  operations  sterilized  absorbent 
cotton  made  into  small  balls  answers  every  purpose. 
These  puffs  of  cotton  are  covered  with  gauze  to  prevent 
the  fraying  out  of  the  fibers.  To  further  improve  them, 
their  centers  may  be  made  up  of  cellulose  or  wood  fiber. 
When  an  absorbent  cotton  sponge  is  moistened  and 
squeezed  out  it  does  not  answer  as  well,  since  its  absorb- 
ing qualities  are  much  reduced ;  the  addition  of  the  other 
material  overcomes  this. 

A  much-used  and  inexpensive  sponge  having  great 
absorbing  power  is  made  in  the  form  of  a  small  compress 
of  sterilized  gauze  held  together  with  one  or  two  stitches 
of  thread.  All  of  the  above  sponges  are  sterilized  with 
the  needed  dressings  and  are  burned  after  use.  When 
removed  from  the  sterilizer  they  are  placed  in  a  suitable 
basin  containing  six  per  cent  sterilized  salt  water.  It  is 
well  to  place  the  receptacle  close  by  the  assistant  who  is 
22 


REQUIREMENTS    DURING    OPERATION      23 

to  sponge.     An  enameled  iron  basin  rack,  as  shown  in 
Fig.  12,  answers  the  purpose  best. 

The  soiled  sponges  are  thrown  into  a  lower  empty 
basin  or  one  placed  at  the  operator's  feet.    As  they  are 


FIG.  12. — BASINS  AND  RACK. 

removed  from  the  solution  they  are  squeezed  as  dry  as 
possible  and  pressed  upon,  rather  than  wiped  across,  the 
operative  field.  It  must  be  remembered  that  the  sur- 
geon's work  must  not  be  hampered  by  slow  or  inefficient 
sponging,  and  that  this  procedure  must  be  quick  and 
timely.  It  is  well  for  the  assistant  to  become  accustomed 
to  the  habit  of  the  operator. 

The  best  assistant  is  one  who  has  acquired  a  method- 
ical and  regular  manipulation,  a  result  dependent  upon 
constant  individual  association ;  such  a  one  is  practically 
invaluable  for  the  skillful  performance  of  plastic  sur- 
gery. He  becomes  not  only  familiar  with  the  one  thing, 
but  cultivates  a  ready  knowledge  of  the  arrest  of  hemor- 


24       PLASTIC   AND   COSMETIC    SURGERY 

rhage  by  digital  compression  when  hemostatic  forceps 
would  hinder  the  ease  of  work,  besides  cultivating  a 
happy  manner  of  holding  retractors  or  spreading  the 
edges  of  the  incisions  with  the  free  hand.  As  in  most 
of  these  operations  hemorrhage  cannot  be  controlled  by 
the  so-called  bloodless  method.  The  assistant  must  con- 
trol the  constant  oozing  by  the  gentle  pressure  of  the 
sponge  quickly  applied  at  short  intervals.  When  the 
sponges  are  squeezed  out  in  salt  solution,  as  hot  as  the 
hand  will  bear  comfortably,  capillary  oozing  is  more 
readily  overcome. 

STERILIZATION   OF  DRESSINGS 

All  dressings  to  be  used  in  covering  wounds,  post 
operatic,  or  otherwise,  must  be  as  scrupulously  clean 
and  free  from  infection  as  the  hands  and  the  instruments 
of  the  operator.  This  is  done  by  means  of  sterilization 
by  dry  heat  or  steam  under  pressure.  For  all  minor 
cases,  small  apparatuses  only  are  -needed.  They  are  usu- 
ally made  of  copper,  often  nickel-plated,  and  so  con- 
structed as  to  contain  a  lower  perforated  instrument 
tray  and  another,  placed  above  it,  for  dressings.  The 
two  are  fitted  into  an  outer  copper  receptacle  with  snugly 
fitting  cover.  A  folding  stand  is  furnished  upon  which 
this  arrangement  is  placed,  and  an  alcohol  lamp  with  as- 
bestos wick  furnishes  the  heating  power.  The  lower  tray 
is  covered  with  water  which,  by  boiling,  fills  the  upper 
compartment  with  steam  evenly  distributed  and  with  suf- 
ficient pressure  to  accomplish  sterilization  in  from  thirty 
to  sixty  minutes.  Metal  hooks  are  provided  with  which 
the  trays  can  be  removed.  A  complete  and  compact  out- 
fit, as  designed  by  Willy  Meyer,  is  shown  in  Fig.  13. 

In  the  above  sterilizer,  or  in  those  of  similar  type, 
there  is  naturally  more  or  less  saturation  of  the  dress- 
ings and  the  possibility,  in  the  event  of  the  entire  con- 
version of  the  water  contained  therein  into  steam,  of 


REQUIREMENTS    DURING    OPERATION      25 

injuring  the  instruments  by  excessive  heat.  To  overcome 
this  defect  the  Wallace  sterilizer  may  be  advantageously 
employed. 


FIG.  13. — WILLY  MEYER  STERILIZER. 


Wallace  Sterilizer. — Its  chief  feature  is  the  addition  of 
a  reservoir  fitting  with  the  separated  sterilizer  into  the 


FIG.  14. — WALLACE  STERILIZER. 


outer  body.     See  Fig.  14.    This  reservoir  automatically 
regulates  the  water  and  steam  supply.    It  is  filled  with 


26        PLASTIC    AND    COSMETIC    SURGERY 


water  and  inserted  into  the  compartment  provided  for 
and  adjoining  the  sterilizer.  Through  an  opening  in  the 
bottom  the  water  is  permitted  to  escape  into  the  sterilizer 
until  the  bottom  of  the  latter  is  covered  to  a  depth  of 
^  inch.  As  the  heat  is  applied  from  the  alcohol  lamp 
this  film  of  water  is  rapidly  converted  into  steam. 

The  dressings  arranged  in  the  large  tray  are  placed 
in  the  sterilizer  and  the  supply  of  steam  is  maintained 
through  the  constant  and  steady  flow  of  -water  from  the 
reservoir,  which  compensates  the  evaporation  in  the  ster- 
ilizer. In  about  twenty  minutes  the  formation  of  steam 
in  the  top  of  the  reservoir  exerts  sufficient  pressure  to 

force  all  the  boiling  water  from 
the  reservoir  into  the  sterilizer  to 
the  depth  of  about  H  inches.  The 
tray  of  instruments  is  now  in- 
serted and  the  process  continued 
for  another  ten  minutes.  Much 
less  heat  is  required  with  this 
apparatus  than  with  those  of  or- 
dinary type,  while  sterilization 
can  be  continued  uninterruptedly 
for  one  and  one  half  hours,  if 
need  be. 

Sprague  Sterilizer.  -  The  most 
perfect  sterilizer  is  that  of  the 
Sprague  type,  in  which  a  dry 
chamber  is  surrounded  by  steam 
under  pressure.  The  apparatus 
is  shown  in  Fig.  15. 

Its  cylindrical  chamber  is  sur- 
rounded by  two  heavy  copper 
shells,  the  space  between  which  is 
occupied  by  the  water.  This  com- 
partment is  entirely  shut  off  from 

the  sterilizing  chamber,  and  as  the  steam  is  generated,  the 
inner,  or  sterilizing,  chamber  becomes  heated  to  a  degree 


FIG.   15. — SPRAGUE   TYPE  OF 
STERILIZER. 


nearly  equal  to  that  of  the  steam  in  the  surrounding 
cylinder;  this  prevents  any  condensation  of  steam  taking 
place  in  the  dressings.  By  opening  the  lever-handled 
valve  at  the  bottom  of  the  sterilizer  in  the  rear,  and  the 
valve  to  the  right,  on  top  of  the  sterilizer,  and  allowing 
them  to  remain  open  for  a  space  of  four  or  five  minutes, 
a  vacuum  is  formed  in  the  sterilizing  chamber.  These 
two  valves  are  then  closed,  the  lower  one  first,  and  the 
steam  from  the  outer  cylinder  is  allowed  to  enter  the 
chamber,  by  opening  the  left  valve  on  top. 

The  contents  should  be  allowed  to  sterilize  for  twenty 
or  twenty-five  minutes  under  a  pressure  of  fifteen  pounds. 
Then  close  the  steam-supply  valve;  open  the  vacuum 
valve  (right)  and  the  lever-handled  valve  at  the  bottom; 
leave  these  open  about  the  same  time  as  in  creating  a 
vacuum  at  the  beginning  of  the  process;  close  both 
valves,  then  open  the  air-filter  valve  on  the  door,  in 
order  to  break  the  vacuum;  the  door  can  then  be  opened 
and  the  dressings  be  taken  out  dry  and  absolutely  sterile. 

The  steam-safety  valve  on  this  sterilizer  is  set  at 
seventeen  pounds,  but  it  can  easily  be  regulated  should  a 
higher  or  lower  pressure  be  desired.  The  door  used  on 
this  apparatus  has  no  packing  of  rubber  or  other  soft 
material  which  wears  or  shrinks  in  time,  a  steam-tight 
joint  being  formed  by  the  bringing  together  of  two  plane 
metal  faces  on  the  door  and  sterilizer  head.  The  door 
hinge  is  so  made  that  these  parts  are  bound  to  come  to- 
gether properly,  without  the  use  of  excessive  caution. 
Springs  on  such  doors  are  liable  to  get  out  of  order  or 
need  replacing,  and  are  avoided  in  this  apparatus.  All 
that  is  necessary  to  lock  or  unlock  the  door  is  to  turn  the 
large  hand  wheel  on  the  front;  the  locking  levers  then 
work  automatically.  These  sterilizers  are  arranged  for 
both  gas  and  steam  heat. 

Sterilizing  Plant. — For  the  ideal  operating  room  the  en- 
tire sterilizing  plant  can  be  had  in  combined  form,  as 
shown  in  Fig.  16.  It  consists  of  a  dry-heat  dressing  ap- 


28        PLASTIC    AND    COSMETIC    SURGERY 

paratus,  just  described,  water  and  instrument  sterilizers, 
all  mounted  on  a  white  enameled,  tubular,  wrought-iron 
frame.  The  chamber  of  the  dressing  sterilizer  is  8^  by  19 
inches.  The  water  sterilizer  has  a  capacity  of  six  gal- 
lons in  each  tank  and  is  fitted  with  natural  stone  filters, 
thermometer,  water  gauge,  safety  valve,  etc.  The 
size  of  the  instrument  sterilizer  is  8  by  15  inches  and  6 


FIG.  16. — STEHILIZING  PLANT. 


inches  deep,  with  two  trays.  Each  apparatus  in  the 
above  can  be  used  independently  of  the  other,  all  being 
arranged  for  gas-heating. 

Dressing  Cases. — All  dressings  should  be  sterilized  im- 
mediately before  operation,  and  not  laid  away  for  later 
use,  as  often  done.  As  the  aseptic  material  is  taken  from 
the  sterilizer  it  is  to  be  placed  in  glass  cases  provided 
therefor,  from  which  they  are  removed,  as  needed,  during 
the  operation. 

A  simple  glass  case,  as  shown  in  Fig.  17,  may  be 


REQUIREMENTS    DURING    OPERATION      29 

used,  or,  better  still,  the  same  can  be  obtained  in  com- 
bination with  an  instrument  table,  as  shown  in  Fig.  18. 


FIG.  17. — DRESSING  CASE. 


FIG.  18. — COMBINATION  DRESSING  CAS*:  AND  TABLE. 


Waste  Cans. — All  soiled  dressings  and  sponges  should 
be  immediately  thrown  into  an  enameled  iron  pail  fur- 
nished for  the  purpose.  At  no 
time  must  soiled  dressings  or 
sponges  be  thrown  upon  the 
floor,  where  they  are  walked 
over,  soiling  the  floor  and,  by 
drying,  contaminating  the  air 
of  the  room.  Cans  for  this 
purpose  are  made  of  steel, 
enameled,  of  the  form  shown 
in  Fig.  19. 

The  contents  of  the  can 'must 
be  taken  from  the  room  after 
each  operation  and  burned. 
The  can  should  be  flushed  with 
carbolic  solution,  and  returned 

FIG.  19.— WASTE  CAN.  to  the  operating  room. 


SUTURES  AND   STERILIZATION 

(Ligatures) 

Silkworm  Gut  and  Silk. — In  plastic  surgery  silkworm  gut 
and  silk  are  used  extensively.  Rarely  is  ordinary  cat- 
gut resorted  to,  because  it  is  absorbed  before  thorough 
union  takes  place,  besides  being  a  source  of  infection, 
either  primarily  from  imperfect  sterilization  or  by  tak- 
ing it  up  from  the  secretions  of  the  deeper  layer  of  skin 
not  affected  by  external  antiseptics. 

The  sterilization  of  silk  is  accomplished  by  boiling  it 
for  one  hour  in  a  1-20  carbolic  solution  and  then  keep- 
ing it  in  a  1-50  similar  solution  (Czerny).  Or  it  may 
be  boiled  in  water  for  one  hour  and  retained  in  a  1-1,000 
alcoholic  solution  of  corrosive  sublimate.  Ordinarily  it 
may,  however,  be  simply  subjected  to  boiling  and  steamed 
in  the  autocleve.  Silkworm  gut  is  treated  in  the  same 
manner.  It  has  greater  tensile  strength  than  silk,  and 


EEQUIREMENTS   DURING   OPERATION      31 

for  that  reason  the  thinner  varieties  are  to  be  preferred 
to  ordinary  silk. 

Catgut.  —  It  is  far  more  difficult  to  prepare  catgut,  but, 
since  it  is  necessary  for  ligation,  the  following  methods 
may  be  considered  best  : 

The  commercial  catgut  as  made  from  the  intestines 
of  sheep,  is  wound  snugly  upon  a  rod  of  glass  and  thor- 
oughly brushed  with  soft  soap  and  hot  water.  It  is  then 
rinsed  free  of  soap,  wound  upon  small  glass  spools,  and 
placed  for  forty-eight  hours  in  a  one-per-cent  alcoholic 
bichlorid  solution,  composed  of  bichlorid  of  mercury,  10 
parts  ;  alcohol,  800  parts  ;  distilled  water,  200  parts.  The 
turbid  fluid  produced  by  first  immersion  is  changed.  Be- 
fore using,  the  spools  are  placed  in  a  glass  vessel  contain- 
ing a  1-2,000  sublimate  alcohol  (Schaffer),  made  up  as 
follows: 

Bichlorid  of  mercury  .............   gr.  vj  ; 

Alcohol  ..........................   ox  ; 

Distilled  water 


These  glass  cases  are  obtainable  for  the  purpose  and  con- 
tain a  second  perforated  compartment  for  the  ligatures 
passing  through  rubber  valves  placed  into  the  openings 
(Haagedorn). 

Catgut  is  generally  prepared  by  soaking  in  oil  of 
juniper  for  one  week  and  then  retaining  it  in  absolute 
alcohol  (Kocher),  or  a  1-1,000  alcoholic  sublimate 
solution. 

Another  method  for  strengthening  catgut,  as  well  as 
to  prevent  its  too  rapid  absorption,  is  to  chromatize  it. 
This  is  done  as  follows: 

The  catgut  is  placed  in  sulphuric  ether  for  forty-eight 
hours,  then  treated  for  another  forty-eight  hours  in  a 
ten-per-cent  solution  of  carbolized  glycerin,  followed  by 
a  five-hour  subjection  to  a  five-per-cent  aqueous  solution 
of  chromic  acid  (Lister).  It  is  allowed  to  remain  in  the 
latter  forty-eight  hours,  then  placed  in  an  antiseptic,  dry, 


tightly  closed  receptacle,  and  finally  soaked  in  1-20  car- 
bolic solution  before  using. 

The  formaldehyd  method  of  Kossman  is  to  immerse 
the  gut  in  formaldehyd  for  twenty-four  hours,  then  wash- 
ing with  a  solution  of  chlorid  and  carbonate  of  sodium 
and  retaining  it  in  the  same  solution.  The  catgut  in  this 
procedure  swells  and  its  strength  is  much  impaired  in 
this  way. 

Any  of  the  above  methods  are  not  above  criticism, 
however,  rigid  as  they  may  seem,  bacterial  growths  hav- 
ing been  obtained  with 
nearly  all  of  them. 

The  dry-air  method 
(Boeckman,  Reverdin) 
is  reliable,  but  the  sub- 
jection of  catgut  to  dry 
air  at  a  temperature  of 
303°  F.  for  two  hours 
results  in  making  it 
tender  and  less  pliable. 
The  Kumol  method 
(Kronig)  is  considered 
the  most  reliable,  even 
under  the  severest 
tests.  This  mode  of 
sterilization  is  accom- 
plished as  follows :  A 
specially  devised  appa- 
ratus of  brass,  with  a 
cast-bronze  top,  both 
thoroughly  nickel-plat- 
ed, is  used.  The  appa- 
ratus of  J.  G.  Clark,  as 

FIG.  20.-CLARK  KUMOL  APPARATUS.          shown   in   Fig.    20,    will 

be  found  excellent.  The 

kumol  is  retained  in  a  seamless  cylinder,  8  by  8  inches, 
which  is  surrounded  on  the  sides  and  bottom  by  a  sand 


REQUIREMENTS    DURING    OPERATION      33 

bath ;  the  flame,  impinging  on  the  bottom,  heats  the  sand, 
thereby  insuring  an  even  heat  to  the  inner  or  sterilizing 
cylinder.  The  catgut,  in  rings,  is  placed  in  a  perforated 
basket  hanging  in  the  cylinder,  which  can  be  raised  or 
lowered  at  will ;  after  drying  for  two  hours  at  80°  C.,  the 
basket  is  dropped,  and  the  catgut  immersed  in  the  kumol, 
at  155°  C.,  for  one  hour;  the  kumol  is  then  drawn  off 
through  a  long  rubber  tube,  and  the  catgut  dried  at  100° 
C.,  for  two  hours ;  it  is  then  transferred  to  sterile  glass 
tubes  plugged  with  cotton. 

Prepared  catgut  of  the  various  sizes  can  now,  however, 
be  purchased  in  the  market,  and  that  offered  by  the  bet- 
ter firms  of  chemists  is  quite  reliable  and  may  be  safely 
used  for  all  plastic  surgery  about  the  face.  It  is  sup- 
plied in  glass  tubes,  either  in  given  lengths,  as  in  the 
Fowler  type,  in  which  the  hermetically  sealed  tube  is 
U-shaped  or  on  glass  spools  placed  in  glass  tubes,  not 
sealed,  but  closed  by  a  rubber  cap,  through  which  the 
desired  length  of  ligature  is  drawn  and  then  cut  off. 


CHAPTER   IV 

PREFERKED   ANTISEPTICS 

ANTISEPTIC   SOLUTIONS 

THESE  are  solutions  used  for  the  destruction  of  and 
to  arrest  the  progress  of  microorganisms  that  have  found 
their  way  into  wounds — the  cause  of  sepsis,  as  exhibited 
by  fever,  suppuration,  and  putrefaction.  These  prepara- 
tions are  called  antiseptics  and  are  used  to  render  parts 
aseptic.  They  vary  much  in  their  destructive  power, 
effect  on  tissue,  and  toxic  properties.  The  reader  is  re- 
ferred to  a  work  on  bacteriology  for  the  specific  knowl- 
edge of  such  on  germ  life. 

The  antiseptic  treatment  of  wounds  was  founded  by 
Joseph  Lister,  1865-70,  then  called  Listerism.  His  one 
chemical  agent  to  accomplish  this  was  carbolic  acid,  but 
many  such  and  more  effective  agents  have  been  added 
since  that  time,  all  differing  in  their  specific  proper- 
ties and  each  having,  for  the  same  reason,  its  particu- 
lar use. 

The  following  group  of  antiseptics  has  been  chosen 
with  a  view  of  giving  the  best  selection,  to  which  the 
author  has  added  a  short  description  of  each,  so  that  the 
surgeon  may  choose  one  or  the  other,  as  the  occasion  may 
demand.  As  a  rule,  an  operator  cultivates  the  use  of  a 
certain  line  of  antisepsis,  especially  in  this  branch  of 
surgery,  experience  being  the  best  guide;  yet  it  is  hoped 
he  may  find  certain  aid  from  those  referred  to,  their  par- 
ticular use  being  pointed  out  from  time  to  time,  as  the 
author  has  had  occasion  to  prefer  one  or  the  other. 
34 


PREFERRED    ANTISEPTICS  35 

Alcohol  (absolute). — This  is  a  well-known  antiseptic, 
but,  because  of  its  ready  evaporation,  is  especially  used 
for  the  hands,  as  described,  and  to  cover  sharp-edged 
instruments  after  sterilization. 

Aluminum  Acetate  (Biirow,  77.  Maas). — A  powerful, 
nontoxic  antiseptic.  Is  used  only  in  two-  to  five-per-cent 
solution.  According  to  Primer,  it  arrests  the  develop- 
ment of  schizomycetes,  and  in  twenty-four  hours  de- 
stroys their  propagation.  It  readily  removes  offensive 
odors  of  wounds ;  its  great  objections  are  that  it  injures 
the  instruments,  and,  because  of  its  astringent  nature, 
roughens  the  skin  of  the  hands.  This,  however,  makes 
it  particularly  useful  for  sponging  to  arrest  capillary 
oozing. 

Boric  Acid  (Lister). — Not  a  powerful,  but  nonirritat- 
ing,  antiseptic.  For  this  reason  it  is  used  extensively  in 
cleansing  mucous  membranes,  and,  when  associated  with 
salicylic  acid,  as  in  the  well-known  Thiersch  solutions, 
composed  of  salicylic  acid,  2  gms. ;  boric  acid,  12  gins. ; 
water,  1,000  gms.,  is  much  used  in  skin-grafting  opera- 
tions. It  is  not  very  soluble  in  cold,  but  readily  in  hot, 
water  and  alcohol.  The  saturated  solution  is  prepared 
by  adding  Bj  to  the  pint  of  boiling  water. 

Benzoic  Acid.  —  Nonirritating,  moderate  antiseptic 
(Kraske) ;  is  prepared  in  1-250  solutions.  Soluble  in  hot 
water  and  alcohol,  but  sparingly  in  cold  water. 

Carbolic  Acid  (Phenylic  Acid). — Not  a  powerful,  but  a 
much-used  antiseptic.  The  purest  acid  should  be  used. 
It  appears  as  a  colorless  crystalline  solid,  liquefied  by 
the  addition  of  five  per  cent  water.  If  more  water  is 
added  the  solution  becomes  turbid,  clearing  when  1-2,000 
is  reached. 

It  is  readily  soluble  in  glycerin,  alcohol,  ether,  and 
the  fixed  volatile  oils.  Solutions  in  alcohol  and  oils  have 
no  antiseptic  effect  (Koch).  The  1-20  aqueous  solution 
is  recommended  by  Lister. 

The  aqueous  solutions  used  in  surgery  are  1-20  and 


36       PLASTIC   AND    COSMETIC    SURGERY 

1-40.  The  weaker  is  used  for  the  operator's  hands,  to 
cover  instruments,  as  already  mentioned,  and  to  im- 
pregnate sponges.  The  stronger  solution  is  used  for  the 
carbolic  spray,  to  cleanse  the  unbroken  skin  about  the  site 
of  operation,  and  to  disinfect  wounds.  Either  solution, 
when  applied  to  an  open  wound,  whitens  the  raw  sur- 
face, coagulates  the  albumen,  and  causes  considerable 
irritation,  which  subsides  quickly  and  is  followed  by 
numbness. 

Such  solutions,  by  virtue  of  their  irritant  nature,  in- 
crease the  serous  discharge  from  a  wound  for  about 
twenty-four  hours,  for  which  proper  drainage  must  be 
provided,  as  by  its  collection  it  would  add  to  the  danger 
by  increasing  inflammation  and  suppuration,  and,  by 
absorption,  even  produce  toxic  effect  generally. 

When  a  cold  solution  is  used  it  should  be  prepared 
by  vigorous  stirring  to  separate  the  globules  of  the  acid. 
Hot  water  insures  perfect  distribution.  After  an  in- 
fected wound  is  washed  with  it,  the  solution  should  not 
again  be  used,  nor  should  any  of  the  acid  be  permitted 
to  remain  in  the  spaces  about  the  wound.  It  will  be  found 
that  many  patients  cannot  tolerate  such  dressings,  and 
that  others  must  be  substituted. 

Large  surfaces  should  never  be  exposed  to  carbolic 
solutions,  because  the  skin  absorbs  them  readily,  fol- 
lowed by  untoward  results.  Dangerous  symptoms  have 
been  known  to  result  from  the  internal  administration  of 
seven  drops  of  the  acid,  and  fatal  termination  has  fol- 
lowed its  use  as  a  surgical  dressing  (Bartley). 

Mild  acid  poisoning  is  first  noted  in  the  urine,  which 
turns  olive  green.  If  the  agent  is  continued,  the  urine 
appears  dark  and  turns  almost  black  on  standing.  The 
coloring  is  due  to  the  presence  of  indican.  If  the  absorp- 
tion is  not  prevented  beyond  this  there  is  dull  frontal 
aching,  tinnitus  aurium,  dizziness,  fainting,  severe  and 
uncontrollable  vomiting.  Untoward  symptoms  are  noted 
by  albuminuria,  total  absence  of  sulphates  in  the  urine, 


PREFERRED    ANTISEPTICS  37 

a  contracted  and  inactive  pupil,  elevation  of  temperature, 
unconsciousness,  muscular  contraction,  and  death. 

The  treatment  consists  in  immediately  removing  the 
cause  and  employing  another  antiseptic.  Support  the 
patient  with  stimulants,  freely  given.  Cracked  ice  and 
brandy  to  allay  the  vomiting.  Small  doses  of  sodium 
sulphate,  frequently  repeated,  as  a  means  of  converting 
the  acid  into  nonpoisOnous  sulphocarbolate  (Bauman). 
Albumen  and  milk  internally.  Magnesium  sulphate,  five 
per  cent. 

Chromic  Anhydrid. — Improperly  called  chromic  acid. 
Made  by  adding  one  and  one  half  parts  sulphuric  acid, 
c.  p.,  to  one  part  of  concentrated  solution  of  dichromate 
of  potash.  Appears  in  saffron-colored  crystals.  It  acts 
as  a  caustic  upon  tissue,  and,  although  a  splendid  anti- 
septic, cannot  be  used  for  such  purposes,  but  is  well 
adapted  for  the  preparation  of  catgut,  as  mentioned. 

Creolin. — Is  an  antiseptic  prepared  from  coal  by  dry 
distillation,  and  is  used  to  stimulate  granulations,  being 
much  more  powerful  than  carbolic  acid.  It  is  nonirritant 
and  practically  nontoxic.  Used  in  two-per-cent  aqueous 
vsolutions,  in  which  it  appears  as  a  turbid  but  effective 
mixture.  It  is  well  suited  for  cleansing  the  hands,  a  five- 
per-cent  solution  having  none  of  the  irritating  or  anes- 
thetic effect  of  carbolic  acid.  Owing  to  the  opacity  of 
the  aqueous  solution,  it  is  not  suitable  for  the  immersion 
of  instruments  for  operation. 

Eucalyptol  (W.  Schultz). — A  nonpoisonous  volatile  oil 
of  considerable  antiseptic  power.  Soluble  in  alcohol,  and 
used  in  three-per-cent  solution.  It  is  claimed  to  quickly 
reduce  the  temperature  in  a  wound.  It  was  much  used 
by  Lister  on  gauze  dressings,  the  formula  of  which  is 
given  elsewhere. 

Glycerin. — It  is  said  to  have  certain  antiseptic  power, 
but  is  used  principally  as  a  staple  solvent  of  carbolic  and 
boric  acid.  Soluble  in  all  proportions  in  water  and 
alcohol, 


38   PLASTIC  AND  COSMETIC  SURGERY 

Hydrargyrum  Bichloratum  Corrosivum  (v.  Bergnicuut, 
Schede,  Buchliolz,  Billroth,  R.  Koch). — The  most  valu- 
able and  effective,  although  the  most  toxic  of  all  anti- 
septics. It  appears  as  a  white  crystalline  powder.  A 
1-50,000  watery  solution  is  efficacious  as  a  germicide 
(Koch;  anthrax  bacilli  killed  by  1-20,000  solution).  Al- 
bumen decomposes  the  bichlorid,  forming  a  white  insolu- 
ble precipitate,  albuminate  of  mercury.  The  same  effect 
takes  place  in  aqueous  solutions  allowed  to  stand  for  a 
time — the  resultant  being  either  calomel  or  metallic  mer- 
cury. The  addition  of  sodium  or  ammonium  chlorid  or 
a  weak  acid,  such  as  tartaric,  prevents  this.  As  much 
sodium  as  of  the  sublimate,  weight  for  weight,  should  be 
used  (Koch).  When  tartaric  acid  is  used  for  this  pur- 
pose, five  times  the  weight  of  the  sublimate  is  employed. 

For  all  surgical  purposes,  except  in  irrigation,  solu- 
tions of  1-500  and  1-1,000  are  used.  For  the  sterilization 
of  wounds  and  during  operations  a  1-3,000  is  employed. 

For  the  ready  preparation  of  such  solutions  subli- 
mate tablets  can  be  obtained,  properly  mixed  with  one  of 
the  above-named  salts.  The  dyed  tablets  are  to  be  pre- 
ferred, to  prevent  error  on  the  part  of  the  user.  Tab- 
lets containing  1  gin.  sublimate,  1  gm.  sodium  chlorid, 
and  colored  with  eosin,  are  advocated  by  Angerer. 

As  metallic  substances  immediately  decompose  the 
bichlorid  in  solution,  instruments  cannot  be  placed  in  it, 
nor  may  it  be  kept  in  metallic  vessels,  glass  being  pre- 
ferred. 

Alcoholic  solutions  of  sublimate  are  used  to  cover 
catgut,  silk,  and  rubber  drainage  tubes. 

Since  sublimate  is  extremely  toxic,  great  care  must  be 
used  to  prevent  its  absorption  or  retention  in  wounds. 
A  strong  solution  must  immediately  be  followed  by  a 
weaker  one. 

Toxic  symptoms  resemble  arsenic  poisoning  very 
much,  and  are  ushered  in  by  an  acute  irritation  of  the 
wound,  especially  if  moist  sublimated  gauze  has  been 


PREFERRED    ANTISEPTICS  39 

used,  vertigo,  and  vomiting-.  The  mucous  membrane  of 
the  mouth  becomes  affected,  followed  by  salivation  and 
bleeding  from  the  gums.  There  may  be  intestinal  hem- 
orrhage and  an  inflammation  of  the  entire  intestinal  tract 
and  kidneys,  increasing  in  severity  and  resulting  in 
death. 

The  early  symptoms  must  be  at  once  met  by  removal 
of  the  cause.  Albumen  and  milk  should  be  given  inter- 
nally, with  stimulants  as  needed.  The  mouth  is  to  be 
rinsed  out  at  frequent  intervals  with  a  saturated  solution 
of  chlorate  of  potash. 

Hydrogen  Peroxid  (Love). — A  powerful  nontoxic  anti- 
septic. It  is  used  in  five-  to  fifty-per-cent  aqueous  solu- 
tions, and  is  most  efficacious  in  suppurating  wounds,  in 
which  it  destroys  the  microorganisms  of  pus.  It  foams 
actively  when  brought  in  contact  with  the  latter,  and  is 
said  to  render  a  wound  aseptic  by  one  or  two  applica- 
tions. A  standard  preparation  of  known  strength  must 
be  obtained,  however,  to  get  good  results. 

lodin. — A  very  powerful  nonirritating  antiseptic. 
Used  especially  for  washing  wounds.  The  proper  solu- 
tion is  made  by  mixing  two  drams  of  the  tincture  (3j 
iodin  to  50j  alcohol)  with  one  pint  of  warm  water  (Bry- 
ant). The  one-per-cent  solution  of  the  trichlorid  is  equal 
in  its  effectiveness  to  a  four-per-cent  carbolic  solution 
(Langenbuch). 

Lysol. — Very  similar  to  creolin,  both  in  composition 
and  effect.  Is  nontoxic,  and  employed  in  two-per-cent 
aqueous  solution.  Appears  as  a  soapy  liquid,  and  forms 
a  clear  solution  with  water. 

Potassium  Permanganate. — An  active  disinfectant,  quick- 
ly destroying  the  odor  of  decomposition,  and  for  that 
reason  is  splendid  for  the  washing  out  of  foul  wounds. 
It  is  nonpoisonous,  and  has  moderate  antiseptic  power — 
the  five-per-cent  solution  killing  resting  spores.  Its  ef- 
fect is  limited  to  a  short  time  only,  as  the  secretions 
from  a  wound  decompose  and  precipitate  it  into  an  in- 


40        PLASTIC    AND    COSMETIC    SURGERY 

active  form.  It  is  employed  in  aqueous  solution,  differ- 
ing in  color  from  light  ruby  to  dark  brown;  that  is, 
1-1,000  to  1-100.  The  solution,  known  as  Condy's  Fluid, 
has  a  strength  of  1-1,000. 

Salicylic  Acid. — A  derivative  of  carbolic  acid,  and  an 
effective  nonirritating  antiseptic.  It  is  only  slightly 
soluble  in  cold  water,  1-300.  When  combined  with  boric 
acid,  it  becomes  more  soluble.  This  antiseptic  cannot  be 
used  for  instruments,  however,  as  it  corrodes  them.  Its 
other  objections  are  that  it  evaporates  quickly  from 
dressings  and  that  it  is  expensive. 

Sodium  Chlorid. — Is  a  common  agent  used  for  the  irri- 
gation of  putrid  wounds  in  two-per-cent  solution.  For 
irrigation  during  aseptic  operation  and  for  covering  ster- 
ilized sponges  it  is  used  in  eight-per-cent  solution  (v. 
Esmarch).  This  corresponding  to  the  normal  salt  solu- 
tion. Its  use  in  connection  with  corrosive-sublimate  solu- 
tions (Maas)  has  been  referred  to. 

Thymol  (Rancke,  Bouillon,  Paquel}. — The  aromatic 
principle  of  thyme.  Efficient  as  an  antiseptic  in  1-1,000 
aqueous  solution.  It  has  a  pleasant  odor,  and  is  nonir- 
ritant  and  nontoxic.  Exhibited  in  colorless  crystals.  An 
excellent  solution  is  prepared  as  follows: 

3  Thymol   20  parts 

Alcohol   10      " 

Glycerin    20      " 

Aquae 1,000       " 

It  is  used  especially  in  washing  out  cavities  where  car- 
bolic acid  cannot  be  employed,  and  for  cleansing  mucous 
membranes  preparatory  to  operation. 

Zinc  Chlorid  (Morgan,  Bardeleben,  Billroth). — Exten- 
sively used  as  an  antiseptic,  especially  in  the  oral  cavity, 
where,  by  sealing  the  lymph  spaces  with  a  plastic  exu- 
date,  it  hinders  the  absorption  of  septic  matter.  It  is 
only  slightly  antiseptic,  however,  in  ten-per-cent  aqueous 
solution.  Zinc  chlorid  represents  the  active  agent  in 


PREFERRED    ANTISEPTIC'S  41 

Burnett's  fluid.  May  be  effectively  employed  in  the  pro- 
portions of  from  twenty  to  forty  grains  to  the  ounce  of 
water.  Care  must  be  exercised  to  prevent  its  retention 
in  alveolar  tissue,  since  it  may  occasion  serious  slough- 
ing. As  a  cleansing  agent  for  infected  wounds  it  is  of 
great  value,  although  the  sulphocarbolate  of  zinc  may  be 
preferred,  as  it  is  less  irritating  and  less  toxic. 

Peroxoles. — Beck  has  introduced  a  group  of  prepara- 
tions, known  as  peroxoles;  liquid  antiseptics  containing 
a  solution  of  hydrogen  peroxid  in  combination  with  other 
disinfectants.  The  preparations  are  composed  of  from 
thirty-three  to  thirty-eight  per  cent  alcohol,  about  three 
per  cent  of  hydrogen  peroxid,  and  one  per  cent  of  thymol, 
menthol,  or  camphor,  the  name  given  them  being  accord- 
ing to  the  last  ingredient — thymosol,  menthosol,  or  cam- 
phorosol.  The  association  with  these  disinfectants 
greatly  increases  the  antiseptic  power  of  hydrogen 
peroxid.  Aqueous  solutions  containing  ten  per  cent  of 
the  peroxoles  are  usually  employed.  These  correspond 
to  a  one-per-cent  solution  of  mercuric  chlorid,  and  pos- 
sess a  more  energetic  action  than  five  per  cent  carbolic 
acid. 

ANTISEPTIC   POWDERS 

Aristol  (Dithymol  Di-iodid)  (Eichhoff). — Reddish- 
brown  powder  containing  forty  per  cent  iodin.  Soluble 
in  ether,  chloroform,  and  fatty  oils,  sparingly  in  alcohol. 
Must  be  kept  in  dark  glass  bottles.  Is  incompatible  with 
corrosive  solutions.  Used  externally  as  iodoform. 

Dermatol  (Bismuth  Subgallate). — An  odorless  yellow 
insoluble  powder,  containing  fifty-three  per  cent  Bi203. 

lodol  (Tetraido  Pyrol]  (Kalle). — A  light  grayish- 
brown  powder,  containing  eighty-nine  per  cent  iodid. 
Slightly  soluble  in  water,  soluble  in  alcohol  and  chloro- 
form. Its  action  is  very  similar  to  iodoform,  and  has 
taken  its  place  to  a  great  extent,  first,  because  it  is  odor- 
less, and  secondly,  because  any  quantity  used  exerts  no 


42   PLASTIC  AND  COSMETIC  SUBGEBY 

toxic  effect  (Wolfenden).  It  is  dusted  upon  the  wound. 
Its  action  is  due  to  the  liberation  of  iodin,  which  acts 
upon  the  albuminous  elements,  and  the  ozone  set  free 
oxidizes  the  products  of  decomposition.  It  has  a  slight 
escharotic  effect,  forming  a  thin  crust  over  the  surface 
to  which  it  is  applied,  thus  effectually  remaining  in  con- 
stant contact  with  it.  That  it  is  quickly  absorbed  is 
shown  by  its  presence  in  the  saliva  and  the  urine. 

Orthoform  (Methyl  Ester  of  Meta-Amido-Para-Oxyben- 
zoic  Acid}. — Nonpoisonous,  white,  odorless  powder  of 
moderate  antiseptic  power,  and  well  suited  for  wounds 
involving  mucous  membranes.  It  has  a  decided  anes- 
thetic effect,  lasting  for  several  hours  upon  painful 
wound  surfaces. 

lodoform  (Formyl  lodid,  Fereol). — A  lemon-yellow 
crystalline  powder  of  penetrating,  saffronlike  odor. 
Contains  ninety-seven  per  cent  iodin.  Insoluble  in  water, 
but  forms  solution  with  alcohol,  ether,  chloroform,  and 
the  fixed  volatile  oils.  Has  a  decided  stimulating  effect 
on  wounds  by  preventing  putrefaction  and  deodorization 
(Mikulicz).  Its  antiseptic  value  has  been  much  dis- 
cussed, but  practically  it  has  found  favor  with  the  ma- 
jority of  surgeons.  According  to  research,  iodoform  is 
a  powerful  antiseptic,  from  the  fact  that  the  product  of 
its  decomposition  in  the  presence  of  germ  life  renders 
the  ptomains  in  a  wound  inert,  thus  preventing  suppu- 
ration, or  at  least  checking  the  absorption  of  such,  which 
is  often  a  serious  matter  in  infected  wounds.  It  is  not 
sterile,  and  may  contain  ptomains  which  in  themselves 
would  produce  pus,  but  as  associated  with  the  iodoform 
do  not  occasion  it. 


CHAPTER   V 
WOUND   DKESSINGS 

THE  dressing  or  treatment  of  wounds,  considered 
herein,  embodies  particularly  that  practiced  by  the  sur- 
geon in  the  performance  of  plastic  operations. 

The  elasticity  of  the  skin  is  especially  serviceable  in 
bringing  about  desirable  restorative  results,  but,  owing 
to  its  extreme  vascularity  and  the  infrequent  supply  of 
venous  valves,  as  in  the  face,  there  is  considerable  dan- 
ger of  infection,  with  rapidly  spreading  septic  inflam- 
mation. 

Sutured  Wounds. — Before  the  wound  is  closed  all  hem- 
orrhage must  be  arrested,  either  by  catgut  ligature,  in 
exceptional  cases,  and  by  torsion  or  pressure,  as  gener- 
ally practiced.  Gauze  sponges  dipped  into  hot  sterilized 
solution  are  most  suitable  for  the  latter  purpose. 

The  edges  of  the  wound  must  be  coapted  perfectly  by 
cutaneous  sutures  of  sterilized  silk  of  suitable  thickness. 
Formaldehyd  catgut  is  often  used  because  of  its  limited 
absorption.  Ordinary  catgut  should  not  be  employed, 
as  its  early  absorption  interferes  with  obtaining  the 
proper  union,  and  by  becoming  softened  invites  sepsis. 

The  wound,  if  small,  may  be  powdered  over  with  any 
of  the  antiseptic  powders,  such  as  aristol  or  iodol.  It 
must  be  remembered  that  such  powders  form  a  hard 
crust  with  the  serous  oozing  of  wounds,  which,  by  reason 
of  pressure  from  the  dressing  applied  over  it,  is  very 
liable  to  separate  the  edges  of  the  wound,  thus  increasing 
the  width  of  the  scar,  a  very  important  factor  in  facial 
surgery. 

43 


44       PLASTIC   AND.   COSMETIC    SURGERY 

Where  perfect  apposition  has  been  made,  the  dusting 
powders  may  be  used  and  a  covering  of  Lister's  protect- 
ive silk  plaster  placed  over  it.  The  edge  of  the  strips 
of  plaster  must  be  incised  at  distances  of  about  -J  inch, 
so  as  to  snugly  take  on  the  curvature  of  the  parts  and  at 
the  same  time  thoroughly  seal  over  the  area  to  prevent 
subsequent  contamination. 

The  plaster  is  made  of  taffeta  silk,  preferably  of  flesh 
color,  coated  on  one  side  with  copal  varnish  and  a  mix- 
ture prepared  as  follows  : 

^  Dextrin  ............................   3j  ; 

Starch  .............................  5ij  ; 

Carbolic  acid   ......................   oi- 


When  applied,  it  should  be  moistened  with  an  antiseptic 
solution  only.  This  can  be  applied  only  to  dry  surfaces, 
however,  and  should  be  rarely  used,  since  subsequent 
hemorrhage  or  oozing  will  raise  the  plasters,  inviting 
sepsis. 

It  is  better,  however,  in  all  cases  to  employ  several 
layers  of  an  antiseptic  gauze,  such  as  fifteen-per-cent 
iodoform  or  boric-acid  gauze  to  cover  the  wound,  and 
back  it  with  absorbent  cotton,  over  which  a  bandage  or 
the  silk  protective  is  applied  to  retain  it.  The  gauze  ab- 
sorbs the  secretions,  at  the  same  time  rendering  them 
harmless. 

At  no  time  should  cotton  be  placed  next  to  the  wound, 
as  it  forms  a  hard  mass  with  the  secretions,  the  removal 
of  which  requires  enough  force  to  injure  or  hazard  the 
union  of  a  new  wound.  Nor  should  a  plaster  dressing 
be  pulled  off  without  thoroughly  moistening  it  first,  with- 
drawing the  various  layers  one  by  one.  The  gauze,  when 
moistened,  readily  leaves  the  wound  without  injurious 
traction.  An  excellent  dressing  for  small,  dry  wounds, 
and  one  that  causes  little  tension,  is  collodium,  or,  better, 
iodoform-collodium  painted  over  the  surface,  The  latter 
be  prepared  as  follows  ; 


WOUND    DRESSINGS  45 

I£  lodof ormurn oj ; 

Collodium    5x. 

[Kiister.] 

To  this  may  be  added  oil  of  turpentine  or  castor  oil, 
which  permits  of  greater  flexibility.  Boric  lint,  applied 
wet,  is  also  good.  It  must  be  moistened  thoroughly  be- 
fore removal.  Larger  wounds  should  be  dusted  over 
with  one  of  the  powders  mentioned  and  covered  with 
folds  of  gauze  and  absorbent  cotton,  held  in  place  with 
gauze  bandages. 

Such  dressings  are  allowed  to  remain  until  the  su- 
tures are  taken  out,  unless  there  is  sign  of  soiling.  As 
these  secretions  readily  decompose,  it  is  best  to  remove 
the  cotton  and  upper  layers  of  gauze  and  renew  them 
every  day,  or  as  often  as  is  necessary.  The  wound,  in 
this  way,  is  not  disturbed  whatever,  and  the  antiseptic 
properties  of  the  lower  fold  of  gauze  is  sufficient  to  keep 
the  wound  surface  clean. 

In  most  superficial  wounds  it  is  best  to  remove  the 
sutures  at  the  end  of  forty-eight  hours,  unless  there  are 
reasons  for  retaining  them  longer,  as  the  coapted  sur- 
faces are  then  sufficiently  united  to  permit  of  other  dress- 
ings, such  as  aseptic  plaster,  now  extensively  used.  Be- 
fore these  are  applied  the  skin  is  washed  with  alcohol  or 
ether  to  assure  a  dry  surface  to  facilitate  adhesion. 

Sutures  drawn  as  stated  leave  no  possibility  of  stitch 
scars  and  reduce  the  occurrence  of  possible  stitch  ab- 
scess to  a  minimum.  As  there  is  always  slight  oozing 
following  their  removal,  aristol  or  iodol  may  be  pow- 
dered over  them  before  applying  the  plasters.  This 
brings  us  to  the  rather  late  question  of  sutureless  coap- 
tation  of  superficial  incisions. 

Sutureless  Coaptation. — This  method,  first  practically 
demonstrated  by  Bretz,  may  be  used  with  considerable 
advantage  in  wounds  about  the  face,  and  overcomes  the 
strain  of  individual  sutures,  besides  avoiding  the  possi- 
bilities of  stitch  infection. 


46       PLASTIC    AND    COSMETIC    SURGERY 


The  method  involves  the  proper  placing  of  strips  of 
plaster  at  either  or  opposite  ends  of  the  wound.  The  dis- 
tance between  the  incision  and  the  edge  of  the  plaster 
must  not  be  less  than  £  inch  or  more,  according  to 
the  length  of  the  wound  and  its  position.  In  place  of 
the  strips  of  rubber  adhesive  plaster,  the  aseptic  Z.  0. 


FIG.  21. 


PLASTEH  SUTURKS. 


FIG.  22. 


plaster  should  be  substituted  to  overcome  the  objections 
of  the  infections  therefrom. 


FIG.  23.  FIG.  24. 

ANGULAR  PLASTER  SUTURES. 


The  inner  edges  of  the  plasters  are  raised  slightly, 
and  interrupted  sutures  are  inserted  through  them  in- 


WOUND    DRESSINGS  47 

stead  of  the  skin  (see  Fig.  21).  They  are  then  tied  as 
shown  in  Fig.  22.  in  angular  incisions  the  plasters  are 
cut  as  desired  to  insure  perfect  coaptation,  as  in  Figs. 
23  and  24.  The  advantages  of  this  method,  besides  those 
already  mentioned,  are  that  the  wound  is  always  open 
for  inspection  and  permits  of  free  drainage.  If  thought 
best,  a  small  strip  of  iodoform  gauze  may  be  placed  over 
the  threads  or  even  under  them,  if  there  is  little  tension. 

Since  the  introduction  of  the  aseptic  Z.  0.  (Lilienthal) 
strips,  the  above  method  may  be  discarded  as  unneces- 
sary and  requiring  too  much  time  for  their  application. 
Strips  of  the  antiseptic  plaster  are  placed  across  the 
wound  at  right  angles,  or,  if  the  surface  be  a  curved  one, 
obliquely  to  the  wound.  The  plasters  are  furnished  in 
strips  of  the  width  desired,  packed  in  two  germ-proof 
envelopes.  They  are  extremely  adhesive  to  dry  surfaces. 
Besides  being  aseptic,  they  are  slightly  antiseptic  and 
nonirritating.  The  strips  are  placed  in  position,  leaving 
an  open  space  between  them  while  the  assistant  brings 
the  edges  of  the  wound  into  position. 

Where  there  is  tension  of  the  parts  this  method  is  not 
to  be  employed.  The  wound  may  be  dusted  as  when  su- 
tured and  dressed  in  the. same  manner.  The  plasters  are 
removed  about  the  sixth  day  by  drawing  the  ends  of  the 
strips  toward  the  wound.  Their  second  application  is 
unnecessary,  regular  dressings  being  substituted. 

From  the  above  it  must  not  be  inferred  that  all  plastic 
wounds  are  amenable  to  the  above  methods,  because 
many  require  specific  treatment,  as  later  described. 

Granulation. — Wounds  left  open  for  granulation  should 
be  dusted  over  with  some  stimulating  antiseptic  powder, 
such  as  aristol  or  boric  acid,  and  then  covered  with  iodo- 
form or  borated  gauze.  The  granulating  surface  must  be 
gently  washed  with  a  mild  solution  of  peroxid. 

Prolific  hypertrophic  granulations,  that  jut  out  over 
the  surface,  are  touched  with  a  lunar  caustic  point,  avoid- 
ing the  epithelial  edge  of  the  wound,  where  it  causes  con- 


48       PLASTIC    AND    COSMETIC    SURGERY 

siderable  pain.  Pale  and  loose  granular  points  should 
be  scraped  away  with  the  sharp  spoon  curette  to  hasten 
better  growth. 

If  the  skin  edges  are  thickened  and  curled  upon  them- 
selves, it  may  be  best  to  curette  or  to  reduce  them  by 
cauterization,  so  stimulating  epitheliar  spreading.  Ster- 
ile gauze  is  then  loosely  laid  upon  the  surface,  backed 
with  a  highly  absorbing  material,  such  at  charpie  cotton 
(Burns),  wood  wool,  and  poplar  sawdust,  retained  in 
gauze  bags  (Porter).  The  absorbing  layer  should  be 
light  and  pervious  to  the  air,  to  facilitate  not  only  free 
absorption,  but  ready  evaporation  of  the  secretions. 

Changing  Dressings. — All  dressings  must  be  absolutely 
sterile  and  all  precautions,  as  primarily  carried  out,  must 
be  followed  in  changing  them. 

It  is  rather  infrequent  to  use  permanent  dressings  in 
plastic  surgery,  but  where  the  wound  appears  aseptic, 
with  a  dry  serous  crust  over  the  line  of  healing,  it  should 
not  be  disturbed  except  for  mechanical  reasons.  The 
latter  are  caused  by  the  coagulated  mixture  of  the  wound 
secretion  and  the  antiseptic  powder  used,  often  aggra- 
vated by  the  median  knotting  of  sutures  or  the  careless 
disposition  of  the  loose  suture  ends.  Not  too  much  can 
be  said  of  carefully  folding  the  free  silk  suture  ends  at 
right  angles  to  the  incisions.  The  ends,  moistened  sub- 
cutaneously,  are  very  liable  to  take  on  septic  infection 
and  communicate  it  to  the  wound — crowded  into  the  very 
wound.  When  becoming  embodied  in  the  coagula  of 
serum  and  antiseptic  powder  it  prevents,  by  pressure, 
perfect  union,  causing  a  wider  scar  at  such  point,  as  well 
as  endangering  the  asepsis  of  the  wound  by  being  pulled 
off  accidentally,  thus  tearing  it  open  and  bringing  on 
hemorrhage. 

The  appearance  of  the  resulting  scar  in  facial  surgery 
is  often  of  as  much  importance  to  the  patient  as  the  oper- 
ation itself,  therefore,  all  care  should  be  exercised  in 
bringing  about  the  very  best  result. 


WOUND   DRESSINGS  49 

For  this  reason,  a  patient  in  poor  health  should  not 
be  operated  upon,  and  any  erosion  of  the  skin  about  the 
seat  of  operation  should  be  thoroughly  healed  before  at- 
tempting plastic  work.  Aristol  dusted  on  an  abrasion 
will  heal  it  quickly. 

If  hemorrhage  follows  the  dressings  of  a  wound,  the 
dressing  should  be  removed  and  the  hemorrhage  con- 
trolled by  pressure,  unless  severe,  and  be  redressed. 
Moist  blood  decomposes  readily  and  is  a  source  of 
early  infection,  unless  careful  drainage  under  antisepsis 
is  established.  At  no  time  should  any  part  of  the  wound 
be  unnecessarily  exposed  directly  to  the  air.  For  small 
wounds,  silk  protective  plaster  may  be  used  to  cover  the 
gauze  dressing,  while  sterile  gauze  bandages  should  keep 
dressings  of  large  area  in  place. 

Bandages,  when  changed,  should  be  cut  away  with  the 
aid  of  the  Lazarewitch  angular  bandage  scissors  and  not 
be  unwound.  It  is  quicker  and  the  undue  pulling  of  such, 
when  glued  by  secretions,  is  liable  to  disturb  the  healing 
of  wounds  and  even  result  in  the  tearing  out  of  sutures. 

The  patient  should  never  be  intrusted  to  dress 
wounds  himself.  In  cases  where  the  dressings  cannot  be 
changed  frequently  proper  precautions  for  drainage  and 
comfort  must  be  observed.  The  temperature  of  the  pa- 
tient should  be  taken  twice  daily;  any  elevation  thereof 
may  indicate  septic  infection  and  demand  immediate 
attention. 

When  a  portion  of  the  ear,  nose,  or  lip  has  been 
severed  by  injury,  the  part  may  be  put  back  into  place  and 
held  by  sutures  and  aseptic  Z.  0.  strips,  powdered  with 
aristol  and  properly  dressed.  Union  usually  takes  place, 
even  in  the  most  unexpected  cases.  None  but  incised 
wounds  of  such  nature  should  be  covered  hermetically 
with  collodium  or  plaster,  as  bruised  surfaces  so  often  in 
this  kind  of  injury  require  perfect  drainage.  The  reten- 
tion of  secretions  produces  infection,  generally  resulting 
in  the  entire  loss  of  the  part. 

5 


50       PLASTIC   AND    COSMETIC    SURGERY 

Wounds  of  the  Mucous  Membrane. — Wounds  of  the  mucous 
membrane  should  be  carefully  drained  and  cleansed 
freely  at  frequent  intervals,  especially  those  about  the 
mouth.  Wounds  of  the  cheek,  if  including  the  mucous 
membrane,  should  be  especially  cared  for,  as  there  is 
here  the  increased  danger  of  infections  from  the  secre- 
tions of  the  mouth. 

Pedunculated  Flaps. — When  pedunculated  flaps  are  left 
free  of  other  attachment,  for  reasons  later  mentioned, 
they  must  be  dressed  as  granulating  wounds.  Here  it 
becomes  necessary  to  support  the  loose  piece  of  skin  in 
such  a  way  as  to  overcome  circulatory  obliteration.  Un- 
necessary handling  is  always  to  be  avoided.  The  fol- 
lowing method  has  been  used  with  the  best  results  by  the 
author. 

The  flap  is  not  dressed  until  all  hemorrhage  has 
ceased.  A  small  pad  of  sterilized  or  borated  absorbent 
cotton  is  covered  lightly  with  ten-per-cent  iodoform 
gauze — cigarette  fashion.  The  surface  of  this  roll  drain 
is  powdered  well  with  aristol  or  iodol  and  it  is  gently 
placed  beneath  the  flap  so  that  it  rests  easily  upon  the 
same.  A  second  and  somewhat  larger  pad  or  roll  of  like 
construction  is  placed  next  to  the  skin  surface  of  the  flap. 
This  is  held  in  position  by  silk  protective  plaster  or  sev- 
eral layers  of  gauze  bandage,  gently,  though  snugly, 
applied. 

The  flap  thus  dressed  should  not  be  subjected  to  pres- 
sure, often  requiring  considerable  care  on  the  part  of  the 
patient,  especially  during  the  night.  Undue  pressure  will 
induce  sloughing  and  must  be  avoided,  even  at  the  ex- 
pense of  comfort  to  the  patient. 

This  dressing  may  be  changed  the  second  day,  when 
the  flap  will  appear  anemic.  Signs  of  discoloration  indi- 
cate gangrene,  which  is  difficult  to  overcome.  In  a  short 
time  the  skin  takes  on  a  pale  pink  color,  which  indicates 
a  reestablishment  of  circulation,  and  granulations  begin 
to  show  themselves  on  the  reverse  side,  which,  as  they 


WOUND    DRESSINGS  51 

multiply,  soon  thicken  the  flap  sufficiently  for  the  purpose 
desired. 

The  dressings  are  continued,  as  begun,  if  there  be  no 
indication  for  interference,  although  the  granulations 
may  be  stimulated  if  too  inactive.  Gently  irritating  the 
granular  surface  with  a  1-3,000  sublimate  solution,  al- 
though rarely  permitted  by  most  surgeons,  does  no  harm ; 
in  fact,  it  is  to  be  recommended  before  reapplying  the  dry 
dressing. 

In  removing  the  dressings  the  edges  of  the  flap  will 
be  found  to  adhere  to  the  gauze ;  this  may  be  gently  lifted 
with  the  tenaculum,  after  previous  softening  with  a  weak 
solution  of  hydrogen  peroxid. 

Pus  (laudable)  is  the  natural  secretion  from  these 
flaps.  Whatever  remains  on  the  surface  is  easily  re- 
moved by  an  antiseptic  solution,  whereupon  the  powder 
is  again  dusted  upon  the  part.  When  the  flap  has  thick- 
ened sufficiently  it  may  be  covered  by  skin  grafts,  but 
this  is  rarely  done  until  it  has  been  properly  implanted 
into  the  area  for  which  it  was  intended  and  only  then 
when  union  between  its  sutured  borders  has  taken  place. 
Ofttimes  one  part  of  a  flap  is  left  unattached,  as,  for  in- 
stance, the  outer  border  of  the  ear,  with  the  object  of 
developing  a  greater  thickness.  This  must  be  cauterized 
along  the  edge  with  the  caustic  pencil,  keeping  the  granu- 
lations within  the  desired  limit  until  the  opposite  layer 
of  skin  has  either  cicatrized  with  it  or  has  been  grafted 
near  it  for  the  same  purpose.  The  surface  is  then  anti- 
septically  treated,  as  any  granulating  surface,  except  as 
otherwise  indicated. 

Foreign  Bodies. — Especial  care  must  be  exercised  with 
wounds  into  which  foreign  bodies  have  been  implanted. 
Under  favorable  conditions  many  are  kindly  received  by 
the  tissues,  but  often  these  rebel  and  even  with  the  great- 
est of  care  in  dressing  such  wounds  will  often  result  in 
the  necessity  for  removal  of  the  substance.  Individual 
cases  of  such  nature  are  fully  referred  to  later. 


CHAPTER  VI 
SECONDARY   ANTISEPSIS 

SEPTICEMIA  FOLLOWING  WOUND   INFECTION 

Symptoms. — After  operations  performed  under  the 
most  thorough  aseptic  or  antiseptic  procedure,  wound 
fever,  more  or  less  marked,  may  be  expected.  It  develops 
a  few  hours  after  operation  and  subsides  in  twenty-four 
or  forty-eight  hours.  If,  however,  the  wound  has  not 
been  properly  rendered  aseptic,  or  in  which  there  is  rea- 
son for  irritation  or  tension,  more  serious  symptoms  may 
develop  about  the  second  or  third  day.  These  symptoms 
increase  with  the  amount  of  infection  in  the  wound  and 
result  in  septicemia,  or  septic  intoxication,  the  outcome 
of  the  absorption  of  ptomains — the  product  of  tissue 
decomposition. 

Inflammatory  fever  is  marked  by  a  sudden  rise  in 
temperature,  100°  to  103°  F.,  with  a  full,  strong,  and 
rapid  pulse,  headache,  anorexia,  coated  tongue,  constipa- 
tion and  diminished  secretion.  If  the  infection  is  severe 
delirium  comes  on. 

If  the  symptoms  are  not  relieved  promptly  the  indi- 
cations of  septicemia  assert  themselves  with  an  in- 
creasing temperature,  between  102°  and  104°  F.,  with  a 
rapid  compressible  pulse  gradually  becoming  weaker. 
The  respirations  are  rapid  and  shallow.  The  tongue  be- 
comes dry  and  discolored  and  the  teeth  are  covered  with 
sordes. 

The  restlessness  disappears  and  apathy,  somnolence, 
and  a  low  type  of  delirium  takes  its  place.  Vomiting  oc- 

52 


SECONDARY    ANTISEPSIS  53 

curs.  There  may  be  a  profuse  diarrhea  and  the  urine  is 
passed  involuntarily.  In  other  words,  septicemia  is  but 
an  aggravated  continuance  of  inflammatory  fever;  un- 
toward symptoms  may  come  on  early,  and  death  may  re- 
sult within  forty-eight  hours. 

On  inspection,  the  infected  wound  appears  highly 
inflamed,  there  is  increasing  swelling,  with  more  or  less 
pain  in  the  part.  The  edges  of  the  wound  appear  pale 
and  everted.  Serous  oozing  comes  from  the  wound.  If 
sloughing  is  to  occur  from  tension  or  low  vitality  of  the 
parts  the  area  becomes  discolored,  assuming  at  first  a 
pale  green  color,  which  turns  into  bluish  brown — and, 
lastly,  brown. 

Treatment. — The  treatment  of  such  wounds  is  to  im- 
mediately relieve  all  tension  by  withdrawing  the  sutures. 
Flush  the  wound  with  peroxid  solution  and  irrigate  thor- 
oughly with  a  1-3,000  bichlorid  solution,  leaving  the 
wound  open  for  a  free  drainage. 

Then  apply  iodoform  gauze  over  the  wound  and 
change  the  dressings  as  often  as  is  deemed  necessary- 
two  or  three  times  a  day.  In  severe  cases  open  the  wound 
thoroughly,  even  by  further  incision,  clean  out  the  con- 
tents of  the  wound,  such  as  foreign  matter,  bloodclots, 
exudate,  or  perhaps  pieces  of  bone  that  may  have  been 
overlooked,  using  a  small,  sharp  spoon  curette  for  the 
purpose.  See  that  the  deeper  recesses  of  the  wound, 
especially  in  those  about  the  nasal  bones,  are  thoroughly 
gone  over. 

Next  irrigate  the  wound  with  a  1-1,000  bichlorid  solu- 
tion. Carbolic  solutions  to  be  of  use  in  the  severer  cases, 
are  too  irritating  and  cause  an  increase  of  the  secretions, 
hence  they  are  not  to  be  used.  Furthermore,  their  toxic 
property  is  not  desirable  and  ofttimes  are  not  well  borne 
by  the  patient. 

The  wound  is  now  loosely  filled  (not  packed)  with 
iodoform'  gauze  to  permit  of  perfect  drainage.  Aseptic 
absorbent  cotton  may  be  placed  over  this. 


54       PLASTIC    AND   COSMETIC    SURGERY 

It  is  not  advisable  to  bring  the  edges  of  the  wound  to- 
gether ;  the  main  object  is  to  overcome  the  spread  of  in- 
fection and  the  toxic  absorption  of  the  wound  product. 

When  the  symptoms  are  severe  moist  dressings,  in 
the  form  of  compresses  dipped  into  1-3,000  bichlorid,  are 
to  be  preferred,  changing  them  every  hour. 

Internally  it  becomes  necessary  to  reduce  the  tem- 
perature and  to  overcome  the  toxemia. 

For  the  temperature  quinin  is  the  best  agent.  In 
milder  cases  it  can  be  given  in  tonic  doses,  associated 
with  antifebrin,  with  or  without  morphin,  to  quiet  the 
patient.  In  severe  forms  quinin  must  be  pushed,  giving 
as  much  as  twenty  grains  at  a  dose,  to  be  repeated  as 
necessary.  A  saline  purge,  magnesium  sulphate  in  full 
doses,  is  useful  to  eliminate  the  ptomains. 

The  strength  of  the  patient  must  be  supported  by  the 
free  use  of  stimulants  and  frequent  small  quantities  of 
nutritious  food.  Milk  with  whisky  is  excellent.  Pepto- 
noids  and  beef  juice  are  given  several  times  in  the  day. 

Favorable  symptoms  are  heralded  by  the  lowering  of 
the  temperature,  the  abatement  of  toxic  symptoms,  the 
reduction  of  the  edema,  and  the  deep  redness,  as  well 
as  the  softening  of  the  hard  and  painful  edematous 
walls  of  the  wound,  followed  by  the  breaking  down  of 
more  or  less  tissue  with  the  production  of  pus. 

GANGRENE 

Gangrene  in  these  cases  is  often  due  to  undue  bruising 
or  pressure  on  the  parts  during  operation,  and  other- 
wise to  the  tension  of  sutures.  It  is  best  to  allow  the 
gangrenous  mass  to  remain,  keeping  it  aseptic  by  anti- 
septic measures,  as  it  is  often  found  that  only  the  super- 
ficial layer  and  the  edge  or  edges  of  the  wound  have 
suffered. 

As  demarcation  is  well  established  the  gangrenous 
portions  may  be  removed  with  the  dressing  or  small  seiz- 


SECONDARY    ANTISEPSIS  55 

ing  forceps.  W dicker's  pattern  of  a  dressing  forceps  is 
shown  in  Fig.  25,  a  toothed  seizing  forceps  being  rep- 
resented in  Fig.  26. 


FIG.  25. — WALCHER  DRESSING  FORCEPS. 


FIG.  26. — TOOTHED  SEIZING  FORCEPS. 

The  wound  from  now  on  may  be  at  first  subjected  to 
a  rather  strong  aqueous  solution  of  hydrogen  peroxid, 
fifty  per  cent,  followed  by  the  same  sublimate  solution 
used  throughout. 

lodoform  gauze  dressing,  with  or  without  dusting  of 
iodoform  or  iodol,  is  continued  with  the  purpose  of  drain- 
ing the  pus  secretion  thrown  off  by  the  granulating  tissue 
which  soon  begins  to  fill  the  wound,  as  well  as  to  exert  its 
antiseptic  and  stimulating  influence  upon  the  granula- 
tions. 

Lazy  or  glassy  granulations  are  removed  with  the 
curette  as  they  appear,  or  a  cauterant,  in  the  form  of  a 
nitrate-of-silver  stick.  Gradually  the  new  tissue  con- 
tracts, the  epidermal  edges  begin  to  fold  over  the  surface. 

Dry  dressing,  in  the  form  of  aristol  or  boric  acid,  may 
then  be  used,  to  produce  ultimate  healing  under  an  asep- 
tic scab,  or  lint  moistened  with  two-per-cent  salicylic  oil 
or  boric  vaselin  is  placed  upon  the  wound.  A  formula 
of  the  latter  is  made  up  as  follows : 

Boric  acid 3  parts 

Vaselin  5      " 

Paraffin    10      " 

A  desirable  boric-acid  oil  for  the  same  purpose  is  com- 
posed of : 


Boric  acid 3  parts 

Cera  alba 4      " 

Ol.  oliva 20      " 

The  latter  must  be  changed  daily  until  cicatrization  has 
been  established. 

If  it  is  more  desirable  to  cover  the  granulating  area 
by  means  of  skin  grafts  it  may  be  accomplished  readily, 
as  later  described.  This  is  usually  resorted  to  when 
there  has  been  loss  of  tissue  from  the  result  of  sloughing, 
although  a  sliding-flap  operation  may  overcome  the  de- 
fect to  a  nicety;  this  is  especially  true  of  wounds  about 
the  anterior  nasal  border. 

If  the  resulting  cicatrice  is  no  larger  than  the  gaping 
wound  it  may  be  excised,  the  skin  at  either  side  is  under- 
mined and  the  edges  are  brought  together,  as  was  origi- 
nally intended. 

ERYSIPELATOUS  INFECTION 

It  sometimes  happens  that  a  wound  takes  on  erysipel- 
atous  infection.  It  is  usually  of  the  simple  variety, 
although  the  cellulo-cutaneous  variety  is  not  rare. 

Causes — The  predisposing  causes  are  septic  infec- 
tion, lowered  vitality,  resulting  from  alcoholism,  poor 
hygiene,  and  nephritis.  The  exciting  cause  has  been  ac- 
credited to  the  erysipelo-coccus  of  Fehleisen,  which  is 
found  chiefly  in  the  more  superficial  channels  of  the 
corium  and  appearing  in  chain  groups  as  seen  micro- 
scopically. 

Symptoms. — The  symptoms  locally  are  the  peculiar 
rosy  rash,  rapidly  spreading  out  from  the  wound  with 
well-defined  margins.  The  affected  part  appears  smooth 
and  edematous  and  is  slightly  raised  above  the  surface, 
the  patient  complains  of  stiffness  and  burning  pain  in  the 
part.  Often  vesicles  form  on  the  affected  part. 

The  temperature  rises  suddenly  to  102°  to  103°  F., 
there  is  nausea  and  vomiting. 


SECONDARY    ANTISEPSIS  57 

Treatment. — The  wound  in  such  cases  must  be  treated 
as  described  in  inflammatory  fever.  Internally  the  usual 
remedies  are  given.  A  local  application  of  sixty-per- 
cent ichthyol  ointment,  covered  with  salicylated  cotton, 
serves  best.  The  skin  may  be  incised  in  various  places, 
washed  with  an  antiseptic  (sublimate  solution  1-1,000) 
and  the  serous  exudation  pressed  out  with  the  sterilized 
hand,  after  which  the  above  ointment  is  applied  under 
absorbent  cotton  (Grliick). 

Antithermic  remedies,  as  obtained  by  the  application 
of  certain  alkaloids,  such  as  cocain,  spartein,  solanin, 
helleborin,  have  been  successfully  used  by  Guimard  and 
Geley. 

Spartein  is  especially  claimed  to  exert  a  happy  in- 
fluence. 

Lately  a  product  under  the  name  of  antiphlogistin 
has  been  used  locally  with  excellent  results  and  its  use 
is  to  be  commended  even  in  local  wound  inflammation. 

If  the  subcutaneous  tissue  is  affected  and  the  surface 
indicates  the  breaking  down  of  tissue,  hot  antiseptic  ap- 
plications are  advisable  or  the  skin  is  incised  down  to  the 
deep  fascia  at  such  places  and  iodoforrn  gauze  is  packed 
into  the  wound  for  several  hours.  Constant  antiseptic 
irrigation  is  then  established  by  means  of  drainage  tubes 
inserted  into  the  various  incised  places,  which  are  con- 
nected to  an  irrigating  apparatus,  so  that  the  antiseptic 
may  reach  all  parts  of  the  infected  area. 

Nontoxic  solutions  are  indicated  in  this  event ;  of  these, 
hydrogen  dioxid,  three  per  cent,  and  boric  acid,  nine  per 
cent,  are  most  suitable.  The  solution  is  allowed  to  trickle 
gently  through  the  wound  and  is  led  off  by  open  tubes, 
that  may  be  connected  in  such  way  as  to  empty  into  a 
receptacle  placed  beneath  the  bed. 


CHAPTER   VII 

ANESTHETICS 

ANESTHESIA  of  the  human  may  be  accomplished  in  two 
ways:  first,  by  the  employment  of  a  general  anesthetic, 
and,  secondly,  by  the  local  use  of  a  narcotic  agent. 

It  is  not  the  intention  of  the  writer  to  dilate  upon  the 
nature  and  use  of  anesthetics,  as  their  value  and  indica- 
tion has  been  fully  exploited.  A  concise  review  of  these 
agents,  however,  will  meet  with  the  approval  of  the  spe- 
cial surgeon,  inasmuch  as  they  have  their  particular  use 
in  individual  cases.  Local  anesthesia  is  undoubtedly  the 
most  extensively  employed,  in  the  performance  of  the 
average  plastic  operation,  yet  in  certain  cases  it  is  con- 
tra-indicated, and  it  is  to  further  the  proper  selection  of 
such  that  the  following  may  be  of  value. 

GENERAL  ANESTHESIA 

It  must  be  understood  that  general  anesthesia  has 
its  many  advantages  and  equally  its  disadvantages.  It 
necessitates  the  early  preparation  of  the  patient  and  a 
thorough  physical  examination  as  to  the  state  of  lungs, 
heart,  and  kidneys.  Patients  having  cardiac  affections 
or  serious  lesions  within  the  lungs  should  be  given  the 
safest  anesthetic  obtainable ;  in  fact,  if  the  operation  can 
possibly  be  done  by  local  administration,  it  should  be. 

It  is  to  be  remembered  that  in  a  majority  of  these 
cases  the  operation  is  undertaken  to  remedy  a  deformity, 
however  caused,  one  that  is  not  necessarily  serious  to 
health,  and  it  would  indeed  be  unwise  to  place  such  a 

58 


ANESTHETICS  59 

body  in  jeopardy  or  to  take  undue  chances  if  they  can  be 
avoided.  Ofttimes  several  operations,  a  few  weeks  apart, 
must  be  done  and  the  frequent  repetition  of  a  general 
anesthetic  might  impair  the  health  of  the  patient — a  con- 
dition not  associated  with  local  anesthesia. 

Neurotic  subjects  often  insist  upon  the  use  of  chloro- 
form and  the  surgeon  is  frequently  tempted  to  adminis- 
ter it,  but  little  objection  should  be  found  with  local 
narcosis,  where  it  can  be  employed. 

PBEPABATION  FOE  GENEEAL  ANESTHESIA 

The  patient  must  not  be  allowed  food  at  least  six 
hours  prior  to  operation.  In  neurotic  and  anemic  sub- 
jects a  full  dose  of  strong  wine  or  whisky  should  be  given 
half  an  hour  before  operation.  Habitual  drinkers  should 
be  given  one  quarter  grain  morphin  sulphate.  All  mov- 
able artificial  teeth,  or  other  foreign  bodies,  must  be  re- 
moved from  the  mouth.  Observe  the  laws  of  asepsis  as 
heretofore  described.  Loosen  the  clothing  of  the  patient 
about  the  neck  and  chest.  Only  a  single  garment  should 
be  worn  during  the  time  of  operation — a  loose,  sterilized 
night  robe,  as  it  may  be  necessary  to  move  the  patient 
about,  and  too  much  or  tight  clothing  might  prove  to  be 
dangerous  in  the  delay  occasioned  by  its  removal. 

The  operating  room  should  never  be  cold  enough  to 
chill  a  patient  so  prepared.  Hot-water  bottles  or  a 
warm  pack  can  be  placed  between  or  about  the  limbs 
to  equalize  the  external  circulation.  This  is  especially 
necessary  when  chloroform  is  administered,  as  this 
lowers  the  temperature  of  the  body.  Have  the  bowels 
and  bladder  emptied.  Choose  the  early  part  of  the  day 
for  operations  of  some  length,  because  the  stomach  is 
then  empty  and  vomiting  with  resultant  gastric  dis- 
turbance will  be  lessened  or  entirely  avoided.  The  anes- 
thetizer  should  be  experienced  and  attend  to  his  duty 
implicitly.  He  must  at  all  times  watch  the  patient,  take 


60       PLASTIC   AND   COSMETIC    SUKGERY 

note  of  the  pulse,  pupils,  and  respiration.  Close  by  he 
must  have  a  mouth-gag,  tongue  forceps,  long-handled 
sponge  holders,  containing  dry  absorbent  cotton  sponges, 
and  a  basin  in  case  of  emesis. 

He  should  quietly  instruct  the  patient  how  to  breathe 
and  at  first  assure  him,  and  as  narcosis  comes  on  com- 
mand him  to  do  what  is  necessary.  No  desultory  or 
detracting  conversation  should  be  permitted.  A  small 
but  efficient  faradic  apparatus  must  be  within  call  of  the 
administrator.  Sterile  vaselin  should  be  smeared  about 
the  nose  and  mouth  to  prevent  skin  irritation. 

CHLOROFORM 

(Guthrie)  The  pure  product  must  be  used.  It  is  a 
colorless,  mobile  liquid,  having  an  ethereal  odor  and 
sweet  to  the  taste.  It  should  not  affect  litmus  or  turn 
brown  with  sulphuric  acid  or  give  a  precipitate  with 
nitrate  of  silver.  If  there  is  emphysema  of  the  lungs, 
bronchitis,  or  renal  disease,  chloroform  is  to  be  preferred 
to  ether,  also  in  operations  about  the  oral  cavity.  Chil- 
dren bear  chloroform  narcosis  better  than  adults. 

Chloroform  first  affects  the  brain,  then  the  sensory 
tract  of  the  spinal  cord,  then  the  motor  tract,  followed  by 


FlQ.    27. SCHIMMELBTJSCH    DROPPING  FlG.    28. EsMARCH    DROPPING 

BOTTLE.  BOTTLE. 

an  involvement  of  the  sensory  path  of  the  medulla,  para- 
lyzing the  respiratory  centers,   while  cardiac   syncope 


ANESTHETICS  61 

may  come  on  at  any  time  during  narcosis.  Death  may  be 
either  due  to  respiratory  or  cardiac  failure,  often  from 
both.  To  overcome  this  the  anesthetic  should  not  be 
crowded,  nor  should  the  apparatus  be  held  too  close  to 
the  mouth  of  the  patient.  The  best  method  of  giving  it  is 
by  means  of  the  dropping  bottle  of  Schimmelbusch  (Fig. 
27)  or  that  of  Esmarch  (Pig.  28)  and  a  simple  mask  or 
apparatus. 


FIG.  29.  —  SCHIMMELBUSCH   IMPROVED  FIG.  30. — ESMARCH  INHALER. 

FOLDING  MASK. 

The  wire  frame  affair,  to  be  covered  with  a  fold  of 
muslin,  designed  by  Schimmelbusch,  is  perhaps  the  best 
(Fig.  29).  Another  splendid  inhaler  is  that  of  the  Leiter 
improvement  of  the  Esmarch  folding  frame  (Fig.  30). 

A  folded  towel,  crumpled  or  pinned  into  a  hollow  oval 
form,  may  be  substituted  for  the  above. 

Begin  by  pouring  about  thirty  drops  upon  the  inhaler, 
gradually  bringing  it  nearer  from  a  distance  of  six 
inches  to  the  mouth  and  nostrils  of  the  patient ;  then  con- 
tinue by  letting  one  drop  fall  upon  the  apparatus  every 
five  or  ten  seconds  until  the  patient  is  thoroughly  anes- 
thetized; then  use  one  drop  about  every  ten  seconds, 
although  it  might  be  necessary  to  push  this  quantity  at 
certain  moments  of  the  operation.  To  obtain  complete 
anesthesia  by  this  method  takes  about  ten  minutes.  The 
vapor  should  be  thoroughly  mixed  with  air  in  the  propor- 
tion of  ninety-five  per  cent  of  air  to  five  per  cent  of  the 


62       PLASTIC    AND    COSMETIC    SUEGEBY 

vapor.  The  amount  administered  during-  operation  can 
rarely  be  determined,  because  of  the  uneven  respiration 
of  the  patient,  who  takes  more  during  frequent  inspira- 
tion than  during  ordinary  breathing.  By  all  means  do 
not  let  the  chloroform  trickle  upon  the  skin  or  into  the 
eyes,  as  it  causes  considerable  irritation. 

The  respirations  are  at  first  full  and  deep,  soon  be- 
coming shallow  and  rapid.  At  first  the  pulse  is  slightly 
stronger  and  fuller  than  the  normal,  but  it  soon  loses 
its  strength  and  volume  and  becomes  more  rapid.  The 
pupils  are  at  first  dilated,  and  as  narcosis  is  induced,  con- 
tract. Should  they  contract  after  this,  during  operation, 
it  is  a  danger  signal  not  to  be  neglected.  Death  may 
come  on  suddenly. 

If  the  patient  struggles  violently  under  early  anes- 
thesia, as  is  often  seen  in  alcoholics  and  athletes,  it  is  not 
advisable  to  push  the  chloroform  nor  should  total  mus- 
cular relaxation  be  effected.  The  arrest  of  reflex  move- 
ment is  all  that  is  required. 

As  the  reflex  action  of  the  cornea  disappears  last  of 
all,  the  anesthetizer  can  use  this  as  a  guide  during  fur- 
ther administration  to  avoid  all  danger.  This  is  accom- 
plished by  gently  touching  the  cornea  with  the  index 
finger,  raising  the  eyelid  with  the  third  finger. 

Chloroform  lowers  the  body  temperature,  due  un- 
doubtedly to  its  aiding  in  the  dissipation  of  heat  and  by 
reason  of  its  effect  on  the  nervous  mechanism  of  heat 
production.  It  is  rapidly  eliminated  by  both  the  lungs 
and  the  kidneys,  because  of  its  high  volatility,  and  as  little 
is  given,  the  irritation  to  these  organs  is  not  as  great, 
volume  for  volume,  as  with  ether. 

In  case  of  asphyxia  the  lower  jaw  must  ~be  pushed  far 
forward,  the  tongue  be  drawn  forward  with  forceps,  and 
the  head  extended  and  lowered,  by  raising  the  feet  off  the 
table.  Cold  water  should  be  dashed  over  the  face  and 
chest.  Slapping  the  chest  with  a  wet  towel  and  vigor- 
ously rubbing  with  hot  cloths  or  brushing  the  palms  and 


ANESTHETICS  63 

soles.  Brandy  and  water,  one  to  two  parts,  can  be  intro- 
duced into  the  rectum,  or  faradization  of  the  nasal  mu- 
cous membrane  can  be  tried.  These  means  failing,  arti- 
ficial respiration  (Sylvester's  method)  must  be  resorted 
to.  This  being  of  no  avail,  tracheotomy  must  be  done. 

If  the  patient  is  induced  to  vomit,  he  should  immedi- 
ately be  turned  on  his  side  to  prevent  the  indrawing  of 
the  ejected  matter  into  the  lungs.  After  it  has  ceased, 
thoroughly  wipe  out  the  mouth  with  a  long-handled 
sponge.  The  anesthetic  must  now  be  crowded  slightly  to 
overcome  the  irritation  of  the  mucous  membrane  of  the 
stomach.  Often  during  the  early  stage  of  anesthesia  the 
patient  stops  breathing,  which  must  be  overcome  by  slap- 
ping the  chest  or  by  two  or  three  forceful  downward 
movements  on  the  epigastrium. 

If  the  face  of  the  patient  takes  on  a  sudden  change  of 
color  or  breathes  heavily  the  anesthetic  should  be  with- 
drawn for  a  few  moments,  until  the  symptoms  abate.  If 
the  mucus  collects  about  the  glottis  it  is  liable  to  cause 
respiratory  difficulty  and  must  be  swabbed  out.  If  the 
inversion  of  the  patient  does  not  relieve  syncope  and  the 
methods  already  mentioned  fail  to  relieve,  injections  of 
normal  salt  solution  into  the  median  basilic  vein  must  be 
employed  as  a  last  means. 

ETHEK 

(Jackson,  Morton.}  Sulphuric  ether  is  used  in  the 
pure  form,  free  from  alcohol  and  water.  It  should  be  a 
colorless,  volatile,  mobile,  and  highly  inflammable  liquid, 
having  a  peculiar  penetrating  odor.  As  its  vapor  is 
much  heavier  than  air,  and  owing  to  its  combustible  na- 
ture, lights  about  the  room  should  always  be  placed  above 
the  patient.  Often  its  vapor  is  ignited  by  the  careless 
use  of  the  electro-cautery. 

Ether  for  anesthesia  should  not  affect  blue  litmus.  It 
should  not  give  a  blue  color  to  ignited  copper  sulphate — 


tlie  test  for  the  presence  of  water.  Alcohol  is  indicated 
when  it  turns  red  by  adding  fuchsin. 

Ether  is  less  toxic  than  chloroform,  therefore  it  re- 
quires a  greater  quantity  to  induce  narcosis. 

If  properly  administered  it  is  by  far  safer  than 
chloroform,  Oilier,  of  Lyons,  reporting  only  one  fatality 
directly  due  to  its  employment  in  four  thousand  patients. 
Tf  the  anesthetic  is  crowded  cyanosis  with  jugular  pul- 
sation is  noted — the  signs  of  inefficient  oxygen  and  car- 
diac distention.  In  most  recorded  cases  of  death  there 
were  complications  of  a  nephritic  pulmonary  nature. 
Ether  should  not  be  used  where  there  is  bronchitis,  gas- 
tritis, or  peritonitis,  owing  to  its  irritant  effect  on  mu- 
cous membranes,  nor  in  nephritis,  aneurysm,  or  advanced 
atheroma.  The  movements  of  the  diaphragm  must  be 
constantly  watched  as  it  is  the  first  to  become  paralyzed 
when  anesthesia  is  carried  too  far.  The  same  care  must 
be  observed  with  the  pupil  for  cerebral  and  the  pulse  for 
cardiac  signs.  Before  giving  this  anesthetic  the  same 
preparations  as  for  chloroform  narcosis  should  be  ob- 
served. The  stomach  should  be'  empty,  the  nose  and 
mouth  smeared  with  vaselin,  and  the  eyes  protected  with 
a  towel. 

At  first  the  patient  is  given  the  ether  with  a  consider- 
able mixture  of  air,  which  should  be  lessened  gradually. 
Coughing  comes  on  quite  often,  which  is  overcome  by 
increasing  the  ether.  Soon  there  comes  a  state  of  re- 
spiratory forgetfulness.  This  is  caused  by  the  irritation 
of  the  trigeminal  and  vagal  nerves  (Hare).  This  is 
corrected  by  dashing  ether  upon  the  epigastrium  or  by 
sudden  and  repeated  pressure  at  this  point.  There  is 
also  choking  and  struggling,  the  face  becoming  suffused 
and  red  and  there  is  an  injection  of  the  conjunctiva.  As 
the  ether  is  pushed  the  patient  becomes  quiet,  followed 
by  a  second  seizure  of  struggling,  so  intense,  that  force 
must  often  be  employed  to  hold  him  on  the  table.  With 
this  there  are  the  various  attacks  of  laughing,  crying, 


ANESTHETICS 


65 


singing,   or  yelling — a   semiconscious   exhibition  of   the 
state  of  the  mind  of  the  individual. 

As  anesthesia  progresses  relaxation  takes  place  and 
the  time  for  operation  is  at  hand.  Often  the  throat  fills 
with  mucus,  owing  to  the  irritant  effect  of  the  vapor  on 
the  mucous  membranes.  This  must  be  wiped  out  with 
the  sponges. 

If  vomiting  occurs  the  head  of  the  patient  is  turned 
to  one  side  until  relieved.  The  mouth  should  be  cleansed 
thoroughly  thereafter  to  prevent  the  contents  getting 
into  the  lungs  and  causing  bronchial  irritation  and  often 
broncho-pneumonia.  If  the  patient  gets  too  little  air, 
shown  by  laryngeal  stertor,  frequent  and  feeble  pulse, 
livid  face  or  pallor,  tonic  spasm,  thoracic  breathing  with 
fixed  diaphragm,  and  drawing  in  of  the  abdominal  walls 
with  inspiration,  the  ether  should  be  let  up  and  the  jaw 
pushed  forward  by  placing  the  fingers  under  the  rami. 
The  tongue  should  be  drawn  forward,  as  already  de- 
scribed, and  such  methods  be  used  as  have  been  men- 
tioned in  connection  with  asphyxia  in  chloroform  nar- 
cosis. The  pupils  fixed  in  dilatation  is  indicative  of 
immediate  danger. 

Strychnin  and  digitalis  should  be  given  hypodermic- 
ally  or  the  intravenous  use  of  ammonia  may  be  em- 
ployed. If  the  stertorous  breathing  is  due  to  mechanical 
causes,  not  to  too  much  ether,  the  hypodermic  use  of  ether 

will  bring  about  reflex  re- 
spiratory movement  by  rea- 
son of  the  local  pain  and 
irritation  thus  produced. 


FIG.  31. — ALLIS  INHALER. 
6 


FIG.  32. — FOWLEB  INHALEB. 


66       PLASTIC   AND   COSMETIC    SURGERY 

The  anesthetic  may  be  administered  with  the  aid  of 
various  masks  or  inhalers.  Simplicity  of  construction  is 
to  be  preferred  to  more  complicated  apparatuses.  The 
aseptic  metal  inhaler  of  Allis  (Fig.  31)  or  the  folding 


FIG.  33. — JUILLARD  MASK. 

form  of  the  same  modified  by  Fowler  (Fig.  32),  are  much 
used  in  the  United  States,  while  the  Juillard  mask — a 
metal  frame  covered  with  several  thicknesses  of  gauze 
—is  used  abroad.  (See  Fig.  33.) 

It  is  to  be  remembered  that  in  operations  about  the 
face  ether  anesthesia  is  not  practicable,  owing  to  the  re- 
peated lifting  of  the  mask  which  allows  the  patient  too 
much  air.  It  can  only  be  given  by  specially  constructed 
inhaling  devices,  which  are  more  easily  used  with  chloro- 
form or  the  mixed  anesthetics.  Their  specific  use  and 
construction  will  be  referred  to  later. 

COMBINED  ANESTHESIA 

It  is  often  desirable  to  get  the  patient  as  quickly  as 
possible  under  anesthesia  and  still  overcome  the  deplet- 
ing effects  of  chloroform  narcosis.  A  common  method 
to  accomplish  this  is  to  give  chloroform  to  the  point  of 
relaxation  and  with  a  change  of  inhaler  continue  with 
ether.  In  this  way  anesthesia  can  be  kept  up  safely  a 
long  time  with  a  minimum  amount  of  ether.  There  are, 
however,  a  number  of  mixtures  used  in  place  of  this  in- 


ANESTHETICS  67 

terchange  of  anesthesia,  all  having  their  particular  merit. 
Some  of  the  best  known  are : 

Alcohol-Chloroform-Ether  (A.  C.  E.  Mixture,  English 
Formula,  1:2:3). — This  induces  rapid  anesthesia  with- 
out the  danger  of  syncope  or  the  other  objections  to 
chloroform  or  ether  when  used  alone. 

Chloroform-Ether-Alcohol,  in  the  proportion  of  3 :  1 : 1,  and 
known  as  Billroth's  mixture,  is  extensively  used  in  the 
same  way. 

Chloroform-Ether. — This  mixture,  in  equal  proportions, 
is  known  as  Tillman's  mixture,  and  has  been  employed  by 
many  well-known  surgeons. 

NITROUS  OXID 

Nitrous  oxid,  as  advocated  by  Sir  Humphrey  Davy, 
is  a  safe  product,  but  the  anesthesia  produced  thereby 
is  of  too  short  duration  to  be  of  practical  value  in  plastic 
surgery.  Its  employment  is  resorted  to  only  for  such 
operations  as  the  opening  of  abscesses  or  the  removal  of 
small  cysts,  etc. 

ETHYL  BROMID 

While  ethyl  bromid  is  a  product  that  cannot  be  said 
to  be  absolutely  safe,  Terrier,  of  Paris,  has  used  it 
largely  to  induce  anesthesia,  following  it  up  with  chloro- 
form. It  should  be  given  freely  with  deep  inspiration, 
the  sixth  inhalation  producing  total  loss  of  conscious- 
ness. A  moment  after  complete  muscular  relaxation  is 
attained,  with  congestion  of  the  face  and  dilated  pupil. 
The  average  time  necessary  to  accomplish  this  is  about 
one  minute,  in  which  about  three  to  five  grams  are  used.  In 
this  way  the  stage  of  excitement  is  overcome  and  imme- 
diate narcosis  is  obtained.  As  the  chloroform  is  substi- 
tuted it  must  be  given  fairly  strong,  reducing  it  gradu- 
ally. The  facial  congestion  slowly  diminishes  and  the 
pupillary  dilation  gives  way  to  contraction.  About  six- 


68       PLASTIC   AND    COSMETIC    SURGERY 

teen  grams  of  chloroform  are  required  to  keep  up  anes- 
tlicsia  for  fifteen  minutes.  The  after-effects  of  chloro- 
form are  entirely  overcome  by  the  above  method. 


ETHYL  CHLOEID 

Hawley,  in  reviewing  the  use  of  ethyl  chlorid  as  a 
general  anesthetic  in  minor  operations,  states  that  after 
several  years  of  more  or  less  constant  use  of  ethyl 
chlorid,  both  in  clinical  and  private  practice,  he  has  still 
to  see  the  first  case  in  which  it  has  caused  him  the  slight- 
est uneasiness.  The  following  precautions  in  its  admin- 
istration should  be  observed:  (1)  The  patient  should  be 
prepared  as  for  chloroform  or  ether;  (2)  whatever  mask 
is  used,  it  should  fit  the  face  snugly;  (3)  a  graduated 
tube  with  a  large  aperture  should  be  used;  (4)  the  anes- 
thetic should  be  well  supplied  with  air  and  as  little  given 
as  possible;  (5)  care  should  be  taken  not  to  present  it  at 
first  in  too  large  a  quantity;  frequently  a  dram  is  quite 
sufficient  for  short  operations;  (6)  the  patient  should 
rest  a  while  after  its  administration,  as  faintness  some- 
times supervenes;  (7)  a  mask. should  be  used  which  does 
not  receive  the  drug  close  to  the  patient's  face,  otherwise 
one  is  liable  to  either  freeze  the  face  of  the  patient  or  to 
cause  asphyxia  by  the  moisture  from  the  expired  air 
freezing  on  the  gauze  in  the  mask,  and  thus  preventing 
the  free  passage  of  air  to  the  patient. 

The  use  of  ethyl  chlorid  has  the  following  advan- 
tages: (1)  Safety  in  administering;  (2)  ease  of  admin- 
istration; (3)  it  rapidly  produces  surgical  anesthesia; 
(4)  it  can  be  used  where  chloroform  or  ether  would  be 
contra-indicated;  (5)  the  patient  can  be  kept  in  any  posi- 
tion during  anesthesia,  upright  or  prone;  (6)  no  cyanosis 
need  occur  during  administration;  (7)  the  patient  re- 
covers promptly  without  after-effects;  (8)  it  is  inexpen- 
sive; (9)  it  can  be  used  for  a  long  or  short  operation  with 
equal  success;  (10)  it  is  especially  useful  as  a  prelim- 


ANESTHETICS  69 

inary  to  other  anesthetics,  decreasing  the  time  required 
for  the  production  of  anesthesia  and  avoiding  shock  and 
discomfort  to  the  patient. 


LOCAL  ANESTHESIA 

ETHYL  CHLORID 

Ethyl  chlorid  is  a  colorless,  mobile  liquid,  which  boils 
at  52°  F.  This  is  furnished  in  thirty-  and  sixty-gram 
glass  tubes,  sealed  with  a  metal  screw  cap  or  spraying 
device.  As  this  cap  is  removed  the  liquid  in  the  tube 
begins  to  boil,  owing  to  the  temperature  of  the  room,  or, 
better,  the  operator's  hand,  and  a  fine  vapor  spray  is 
ejected  from  the  opening. 

The  tube  end  is  held  from  six  to  eight  inches  from  the 
part  to  be  anesthetized.  Immediately  the  skin  is  frosted 
over  and  the  lanugo  hairs  become  covered  with  snow. 
The  skin  turns  white  and  becomes  slightly  elevated,  ap- 
pearing to  be  thickened;  at  the  same  time  the  patient 
feels  a  stinging  pain  in  the  area.  This  may  be  overcome 
greatly  by  first  smearing  the  part  with  sterile  vaselin. 
In  a  few  moments  the  skin  is  frozen  and  rendered  an- 
talgic,  and  operations  of  short  duration  can  be  per- 
formed. The  only  disadvantage  with  this  method  is  that 
the  part  to  be  operated  on  is  frozen  stiff,  hence  the  skin 
cannot  be  neatly  dissected  away  from  the  subcutaneous 
tissue  as  under  other  local  anesthesia,  nor  can  the  tissues 
be  moved  about  as  readily,  as  in  the  case  with  flap  opera- 
tions, owing  to  this  stiffness. 

The  parts  thaw  out  quickly  with  a  returning  sen- 
sitiveness, and  it  may  be  necessary  to  apply  the  spray 
repeatedly  until  the  operation  has  been  completed.  If 
elastic  constriction  can  be  employed,  the  antalgic  effect 
is  more  quickly  produced  and  more  lasting. 

As  the  parts  thaw  out  there  is  considerable  prickling, 
which  can  be  mitigated  by  applying  sponges  soaked  in 


70        PLASTIC    AND    COSMETIC    SURGERY 

hot  sterilized  water.     More  or  less  redness  of  the  skin 
will  be  noted  even  for  some  time  after  the  operation. 

COCAIN 
(MetliylbeMzoylecgonin) 

(Gadeke,  Nieman,  Bennett,  Roller. )  Cocain  is  the 
alkaloid  derived  from  several  varieties  of  Erythroxylon 
coca.  It  should  appear  as  a  permanent  white  crystalline 
powder  in  colorless  prisms  or  flaky  leaflets.  The  salt 
used  for  anesthetic  purposes  is  the  hydrochlorid ;  it  is 
soluble  in  0.4  part  water,  2.6  parts  alcohol,  18.5  parts  of 
chloroform,  and  insoluble  in  ether. 

Locally  applied  on  mucous  membranes  and  open 
wounds,  it  exerts  an  analgesic  effect,  but  not  of  the  un- 
broken skin.  Punctures  or  abrasions  are  necessary  to 
permit  of  absorption  in  this  event.  When  locally  ap- 
plied it  paralyzes  the  peripheral  sensory  nerves,  and  at 
first  blanches  the  parts  by  reason  of  its  active  contrac- 
tion on  the  arterioles,  which  is  soon  followed  by  marked 
congestion. 

Krymoff  has  made  extensive  experiments  to  deter- 
mine the  anesthetic  effects  of  cocain  solutions  sterilized 
in  various  ways.  He  claims  that  the  best  results  in  minor 
surgery  are  obtained  with  the  one-per-cent  solution  pas- 
teurized at  60°  C.  for  three  hours.  The  same  solution 
pasteurized  at  80°  C.  for  two  hours  or  at  120°  C.  for  fif- 
teen minutes  gave  results  far  less  satisfactory. 

While  the  pasteurized  solutions  accomplished  an  an- 
esthesia lasting  from  one  to  two  hours,  sterilized  solu- 
tions (boiled  at  100°  C.)  overcame  pain  only  for  a  period 
between  twenty  and  thirty  minutes. 

Pasteurized  solutions  have  the  advantage  of  being 
sterile  and  do  not  decompose  as  the  boiled  solutions 
would.  The  pasteurization  is  accomplished  as  follows: 
The  necessary  amount  of  cocain  is  dissolved  in  sterilized 
water.  The  solution  is  put  into  a  sterilized  glass  bulb, 


ANESTHETICS  71 

•\ 

which  is  sealed  hermetically  and  subjected  to  a  tempera- 
ture of  60°  C.  for  three  hours. 

Since  cocain  is  a  nerve  poison,  its  systemic  absorption 
must  be  avoided.  The  constitutional  effects  of  a  given 
amount  injected  about  the  heajl,  face,  and  neck  are  more 
marked  than  when  injectedan  other  parts  of  the  body  or 
extremities.  This  is  due  to-'two  causes:  a  more  rapid 
absorption  and  the  proximity  to  the  brain  (Eicketts). 
For  this  reason  less  cocain  should  be  used  and  the  blood 
vessels  be  avoided.  ^"\l 

Idiosyncrasy  influences)  greatly  these  toxic  effects. 
In  neurotic  patients\pf  irritable  and  impressionable  type 
the  hypodermic  use  oiQfcis  agent  has  specially  induced 
serious  syncope.  Very  serious  symptoms  and  even  death 
have  been  caused  brcits  local  use  X^  grain  hypoder- 
mically).  ^V  (L 

Untoward  effects  aremanifested  by  nausea,  vertigo, 
emesis,  syncope,  follo\%#d  by  clonic  convulsions,  delirium, 
and  death.  ^J* 

Cocain  first  stimulates,  then  paSJ^lyzes,  the  pneumo- 
gastric  nerve ;  thej  inspiration  is  Nfipt  accelerated,  and 
then  paralyz&sL  death  being  que  to  failure  of  respira- 
tion.  \  \J 

Should  tftese  symptoms  MenM  Ihe  patient  should  be 
placed  on  his  b^cl^with  the4iead\Vw.  Amyl  nitrate  in- 
halations act  asHq^  antidote  anooreduce  the  cerebral 
anemia  (Fginberg).  Morphin  or  caffein  is  to  be  given 
hypodermicxlly,  or  the  former  is  associated  with  potas- 
sium bromid  internally. 

To  overcome  the  toxic  qualities  of  the  anesthetic  it 
may  be  combined  with  morphin  in  solution,  Schleich's 
solution  being  /fell  known.  It  is  composed  as  follows: 


Cocain  tnurias   0.1 

Morph.  sulph 0.025 

Sodium  chlor 0.2 

Aquae  sterilis 100.0 


72       PLASTIC   AND    COSMETIC    SURGERY 


Gauthier  suggests  the  addition  of  one  drop  of  a  one- 
per-cent  solution  of  nitroglycerin  to  the  quantity  in- 
jected and  repeated  to  prevent  the  unfavorable  after 
effects. 

Solutions  of  cocain  are  to  be  made  up  fresh  each  day, 
as  they  become  moldy  on  standing.  They  cannot  be  ster- 
ilized, for  the  reason  that  a  temperature  of  213°  F.  ren- 
ders them  useless.  The  solution  is  most  active  at  50°  F. 
(Costa). 

For  hypodermic  purposes  two-  to  ten-per-cent  solu- 
tions are  employed,  the  four  per  cent  being  more  gen- 
erally used,  not  more  than  0.1  gram  of  the  agent  being 
introduced  (Hanel,  ano). 

For  the  introduction  of  the  solution  the  ordinary 
Pravaz  syringe  can  be  used,  a  modification  of  which  being 
known  as  the  "  Simplex  "  (Fig.  34).  It  is  a  glass  instru- 
ment, without  screw  threads  within  the  needle  base,  and 
has  a  sterilizable  fiber  piston.  The  only  disadvantage 


i 


FIG.  35. — KOLLE  IMPROVED  PRAVAZ  SYRINGE. 


Fio.  34. — SIMPLEX 
SYRINGE. 


FIG.  36. — "SuB-Q"  SYRINGE. 


offered  by  this  syringe  is  the  lack  of  finger  rests.    The 
author  has  added  a  removable  nickel-plated  sleeve  with 


ANESTHETICS  73 

finger  rings  to  slip  over  the  glass  barrel,  as  shown  in 
Fig.  35.  The  advantage  of  this  modification  will  be  ap- 
preciated when  injections  are  made  into  dense  or  cica- 
tricial  tissue  where  considerable  pressure  is  necessary 
for  the  introduction  of  the  solution. 

Another  excellent  syringe  for  the  purpose  is  the 
metal-cased  instrument  known  as  the  "  Sub-Q "  (Fig. 
36) ;  the  barrel  and  piston  in  this  are  of  glass,  an  asbes- 
tos packing  being  wound  over  the  piston  head. 

Metal  needles  with  large  thread  or  smooth  ends  are 
employed.  As  the  asbestos  packing  contracts  in  drying, 
the  piston  should  be  removed  from  the  barrel  and 
cleansed  immediately  after  use,  and  not  be  introduced 
into  the  barrel  until  both  the  asbestos  windings  and  the 
inside  of  the  barrel  have  been  moistened  with  warm 
sterile  water.  This  precaution  prevents  the  cracking  of 
the  instrument  through  undue  pressure  exerted  on  the 
end  of  the  piston  rod  at  the  time  of  use. 

To  render  the  primary  introduction  of  the  needle 
painless  the  area  might  be  sprayed  for  a  moment  with 
ethyl  chlorid.  After  carefully  preparing  the  site  of  op- 
eration, the  subcutaneous  injections  are  made  in  a  some- 
what oval  or  circular  manner,  the  first  infiltration  of  the 
cocain  rendering  the  succeeding  points  analgesic. 

It  will  be  noted  that  the  skin  becomes  whitened  and  is 
raised  in  little  tumors,  with  the  point  of  puncture  as  a 
center.  The  various  punctures  are  so  placed  that  the 
borders  of  these  tumors  meet,  the  entire  site  becoming 
edematous.  If  by  constriction  the  part  can  be  rendered 
ischemic,  the  analgesic  effect  is  prolonged,  reducing  the 
systemic  absorption  to  a  minimum. 

The  subsequent  nausea  often  following  may  be 
promptly  overcome  by  the  use  of  a  mixture  of  creosote, 
four  drops  in  limewater.  For  mucous  surfaces  the  an- 
esthetic may  be  applied  with  absorbent  cotton  and  al- 
lowed to  remain  about  five  minutes.  In  deeper  wounds 
than  those  involving  skin,  deeper  injections  must  be  made. 


74   PLASTIC  AND  COSMETIC  SURGERY 

The  effect  of  the  anesthetic  as  above  employed  is 
practically  immediate,  and  the  operation  can  proceed  at 
once.  Its  duration  is  from  fifteen  to  twenty  minutes  for 
subcutaneous  surgery,  but  where  the  deeper  structures 
are  involved  subsequent  injections  must  be  made  to  con- 
trol the  pain. 

BETA  EUCAIN 
(Benzoylvinyldiacetonalkamin) 

(Merling,  Vinci.)  White  powder,  soluble  in  33 
parts  of  water.  While  the  effects  of  eucain  are  im- 
mediate and  produce  anesthesia  as  thoroughly  as  cocain, 
it  has  the  objection  of  producing  local  hyperemia  and 
increased  edema  of  the  parts  injected.  This  often  in- 
terferes with  the  successful  outcome  of  the  first  opera- 
tion, as  will  be  later  shown.  The  advantage  over  cocain, 
however,  is  that  a  solution  of  eucain  can  be  sterilized  by 
boiling  without  reducing  its  usefulness,  which  in  itself 
is  an  item,  since  both  are  expensive,  and  if  we  must  pre- 
pare a  cocain  solution  fresh  for  each  day  we  must  discard 
all  that  has  not  been  used,  while  with  eucain  the  same 
preparation  can  be  safely  used  over  and  over,  after 
proper  sterilization. 

The  two-  and  three-per-cent  solutions  are  most  em- 
ployed to  the  extent  of  from  10  to  60  minims.  Its 
subcutaneous  effect  is  immediate,  lasting  from  ten  to 
twenty-five  minutes.  When  applied  locally  to  mucous 
membranes,  the  five-per-cent  solutions  are  used. 

Principally  it  may  be  said  that  eucain  does  not  ex- 
hibit the  toxic  properties  of  cocain,  the  author  having 
employed  it  in  over  5,000  cases  with  no  untoward  effect. 

LIQUID  AIR 

Liquid  air  is  suggested  as  a  means  of  local  anesthesia 
by  A.  C.  White.  He  recommends  its  intermittent  ap- 
plication instead  of  freezing  the  part  as  with  ethyl 


ANESTHETICS  75 

chlorid.  It  is  sprayed  on  the  parts  and  produces  imme- 
diately anemia  and  insensitiveness.  There  is  no  hemor- 
rhage during  its  use,  so  that  dressings  may  be  applied 
before  the  parts  assume  their  circulatory  function;  an 
advantage  of  considerable  value  in  plastic  surgery.  No 
untoward  results  follow  its  use. 

STOVAIN 
{Benzoyl-etliyl-dimetliylainin-opropanol  hydrochlorid) 

(Fourneau.)  This  is  the  latest  preparation  advocated 
for  local  anesthesia.  It  is  a  synthetic  product,  derived 
from  tertiary  amyl  alcohol.  It  is  less  toxic  than  cocain, 
and  has  been  used  more  or  less  in  the  past  years  experi- 
mentally, but  the  consensus  of  opinion  seems  to  be 
against  its  use.  Jennesco  has  used  it  extensively  in  con- 
junction with  strychnin  in  spinal  anesthesia,  but  the  sur- 
geon in  general  has  not  taken  kindly  to  it.  In  plastic 
surgery,  as  used  locally,  it  has  been  little  employed,  eu- 
cain  being  the  most  serviceable  for  the  purpose. 


CHAPTER    VIII 
PRINCIPLES    OF   PLASTIC    SURGERY 

PLASTIC  surgery  is  resorted  to  in  covering  defects  of 
the  skin  due  to  congenital  or  traumatic  malformation, 
injuries,  burns,  the  removal  of  neoplasms,  or  the  ulcera- 
tive  processes  of  disease.  Furthermore,  it  can  be  em- 
ployed cosmetically  for  the  rebuilding  of  organs,  whole 
or  in  part,  or  for  their  reduction  when  abnormally  de- 
veloped. This  applies  particularly  to  the  nose,  ears,  and 
lips,  wherein  it  may  involve  either  the  skin  alone  or  the 
mucous  membranes,  or  all  the  tissue  making  up  the  parts 
operated  on. 

Incisions. — The  incisions  in  plastic  surgery  are  to  be 
made  obliquely  into  the  skin  rather  than  at  right  angles 
to  the  surface,  the  former  permitting  of  better  apposi- 
tion, and  undoubtedly  causing  less  epidermal  scar.  The 
incisions  include  the  skin  only,  except  when  otherwise 
stated. 

Sutures. — Sutures  should  be  placed  not  more  than  £ 
of  an  inch  apart  and  be  made  to  include  the  skin  only, 
unless  it  is  deemed  advisable  to  employ  deeper  ones  to 
relieve  undue  traction,  which  often  results  in  suture  scars 
and  ofttimes  tissue  loss,  necessitating  further  operation. 
The  latter  may  be  obviated  by  placing  every  other  stitch 
at  greater  distance  from  the  free  edge  of  the  skin,  that  is, 
into  the  undissected  border. 

Intracutaneous  sutures  may  also  be  employed,  but 
these  are  rarely,  if  ever,  necessary  if  the  apposition  has 
been  properly  accomplished.  To  relieve  tension,  harelip 
76 


PRINCIPLES   OF    PLASTIC    SURGERY       77 

pins  are  also  used,  as  later  described.  Catgut  of  such 
size  as  would  be  suitable  because  of  its  ready  absorption 
is  not  to  be  employed  for  skin  suturing,  fine  twisted  silk 
or  selected  horsehair  being  the  best  material. 

Formaldehyd  catgut  can  be  used  if  it  is  desirable ;  its 
fine  strands  withstand  absorption  to  a  greater  degree 
than  the  ordinary. 

Needles. — Very  fine,  flat,  round-eye  needles,  such  as 
Haagedorn's,  Nos.  12  to  15,  £  or  f  circle,  are  the 
most  serviceable  in  skin  work,  as  they  incise  the  skin  in 
penetrating  and  leave  an  elongated  slit,  which  heals  read- 
ily, rarely  leaving  a  needle  scar.  The  selection  of  needles, 


FIG.  37. — %  CincLE  HAAGE-  FIG.  38. — CRESCENT  CURVE 

DORN  NEEDLES.  HAAGEDORN  NEEDLES. 


however,  must  be  left  to  the  operator,  many  preferring 
the  one  variety  to  the  other.  Split-eye  needles  are  quite 
convenient,  but  they  break  more  readily,  and  while  they 
work  best  with  fine  silk,  this  is  more  readily  withdrawn 
from  the  eye  at  undesirable  times.  For  very  delicate 
work  the  needles  mentioned  are  the  best. 

Needle  Holders. — Inasmuch  as  the  needles  used  in 
plastic  operations  are  very  small  and  fine,  proper  needle 
holders  must  be  used.  The  requisitions  are  that  the  jaw 
be  long,  narrow,  of  soft  copper,  and  that  they  have  an 
automatic  lock  attachment.  Plain  needle  holders  may  be 
used,  but  at  times  the  locking  device  is  very  necessary 
and  saves  time.  The  most  serviceable  of  this  class  are 
the  Kersten  modification  of  Mathieu,  an  uncomplicated 


FIG.  39. — KERSTEN-MA-  FIG.  40. — HAAGEDORN        FIG.  41. — POZZI-HAAGE- 

THIEU  NEEDLE  HOLD-  NEEDLE  HOLDER.  DORN  NEEDLE  HOLD- 

ER. ER,  5  IN. 


FIG.  42. — WEBER-HAAGEDORN  NEEDLE  HOLDER,  FIG.  43. — NEEDLE  WITH 

6  IN.  SUTURE  CARRIER. 

78 


PRINCIPLES   OF    PLASTIC    SURGERY       79 

holder  of  merit  (Fig.  39),  and  the  small  Haagedorn, 
five-inch  narrow-jaw  holder  (Fig.  40),  or  the  holders 
taking  similar  needles,  as  shown  in  Figs.  41  and  42, 
known  as  Pozzi's  and  Weber's  modifications,  respectively. 

Holders  with  cup  jaws  serrated  at  different  angles 
are  of  no  value,  unless  other  needles  are  used  with  them, 
as  they  invariably  break  the  flat  ones. 

To  overcome  the  necessity  of  rethreading  or  the  use 
of  many  needles,  the  very  ingenious  holder  with  ligature 
carrier  can  be  used,  especially  where  the  surgeon  does 
not  care  to  sew  with  a  long,  free  thread.  The  silk  can 
be  sterilized  on  the  metal  spool  separately  and  inserted 
within  the  handle  of  the  holder,  as  shown  in  Fig.  43. 


METHODS   IN   PLASTIC    OPERATIONS 

THERE  ARE  FIVE  DISTINCTIVE  METHODS  EMPLOYED  IN 
PERFORMING  PLASTIC  OPERATIONS: 

I.  Stretching  of  the  margins  of  the  skin. 
II.  Sliding  flaps  of  adjacent  skin. 

III.  Twisting  pedunculated  flaps. 

IV.  Implantation  of  pedunculated  flaps  by  bridging. 
V.  Transplantation  of  nonpedunculated  flaps  or  skin 

grafting. 

This  classification  differs  from  that  heretofore  gener- 
ally given  in  the  meager  literature  on  the  subject,  but  the 
author  believes  his  arrangement  to  be  more  scientifically 
exact  as  well  as  simpler  for  recording  and  history 
purposes^ 

I.  STRETCHING  METHOD 

In  the  stretching  method  the  defect  is  neatly  excised, 
so  as  to  freshen  the  margins  to  be  brought  together.  It 
may  be  necessary,  if  the  defect  is  too  large  for  free  ap- 
position, to  dissect  the  skin  away  from  the  underlying 
tissue  to  render  it  more  movable  and  to  overcome  ten- 


80   PLASTIC  AND  COSMETIC  SURGERY 

sion.  The  shape  of  the  incision  depends  largely  upon  the 
nature  of  the  defect  and  must  be  made  with  a  view  of 
leaving  as  little  scar  as  possible.  Where  the  defect  is 
somewhat  linear,  or  elongated,  an  elliptical  incision  (^4) 
is  made,  as  in  Fig.  44,  and,  if  necessary  because  of  too 


I 

\m/ 
v 

FIG.  44. 
CELSUS  INCISIONS. 


FIG.  44a. 
CELSUS  RELIEVING  INCISIONS. 


great  tension,  the  skin  is  undermined  sufficiently  to  allow 
the  parts  to  come  together ;  if  this  cannot  be  done  readily, 
two  semilunar  incisions  (6,  b)  must  be  added.  This  will 
allow  of  ready  coaptation.  The  wound  is  then  brought 
together  with  an  interrupted  suture,  appearing  as  in  Fig. 
44a,  the  semilunar  spaces  being  allowed  to  heal  by  granu- 
lation. 

In  excisions  in  small  rhomboidal  form,  the  skin  is 
merely  dissected  up  and  around  the  wound,  the  same  as 


FIG.  45. 
RHOMBOID  EXCISION. 


FIG.  46. 
UNION  OF  RHOMBOID  EXCISION. 


in  Fig.  45,  and  the  wound  is  sutured  in  linear  form,  as 
shown  in  Fig.  46. 


81 


If  the  defect  is  oblong  in  form,  the  angles  are  brought 
together  wholly,  leaving  a  small  surface  to  granulate, 
as  in  Fig.  47,  or  they  are  drawn  toward  the  center, 


FIG.  47. 
OBLONG  EXCISION. 


FIG.  48. 
COAPTATION  OF  SAME. 


leaving  the  remainder  of  the  parallel  lines  to  be  sutured, 
as  shown  in  Fig.  48. 

Another  method  of  overcoming  a  smaller  defect  of 
similar  form  is  to  excise  a  small  triangular  portion  of 


FIG.  49. 
BlTRIANGULAR  EXCISION. 


TT  T  TTTT 

FIG.  50. 
LINEAR  COAPTATION. 


skin  at  either  side  of  the  oblong,  as  in  Fig.  49,  and  then 
with  or  without  dissection  bringing  the  margins  together 
in  linear  form,  as  in  Fig.  50. 


TT  f  TT 


X 


FIG.  51. 
TRIANGULAR  EXCISION. 


FIG.  52. 
COAPTATION  OF  WOUND. 


Likewise  can  a  triangular  fault  be  brought  together 
by  sewing  in  the  greater  angles  and  making  a  linear 
wound  of  the  remaining  part,  as  in  Figs.  51  and  52. 

7 


82       PLASTIC    AND    COSMETIC    SURGERY 

Again,  a  triangular  defect  may  be  remedied  by  add- 
ing a  smaller  triangle  at  each  end  involving  healthy  skin, 


FIG.  53. 

TRIANGULAR    EXCISION    WITH    RE- 
LIEVING INCISION. 


FIG.  54. 
COAPTATION  OF  WOUND. 


utilizing,  if  need  be,  the  relieving  incisions,  as  in  Figs. 
53  and  54. 

II.  SLIDING  METHOD 

Following  the  principle  of  Celsus,  as  mentioned  on 
page  8,  defects  can  be  overcome  in  various  ways.  The 
incisions  may  be  straight  or  curved,  and  one  or  more 


^fllp^ 

t- 
<  *- 

h 

—  r 

«• 

M0 
-• 

-1- 

T 

T" 
r 

T1 

I 

-T" 

-  r 

Jl     JL     JL 
FIG.  55.                                                        FIG.  56. 
SQUARE  EXCISION.                               COAPTATION  OF 

1     JL 
WOUND. 

flaps  of  skin  are  raised,  slid,  and  sutured  over  the  part 
to  be  covered.  The  simplest  form  is  the  covering  of  a 
square,  as  shown  in  Figs.  55  and  56. 

If  the  square  be  too  large  for  the  above  method,  the 


^ 
t 

e 

r  T  T 

-* 

* 

H" 

-f 
-< 
-< 

\TT 

111     «  '_ 
1    1    I     1  l" 

"*!  1     111  — 

FIG.  57. 
SQUARE  EXCISION. 


FIG.  58. 
COAPTATION  OF  FLAPS. 


PRINCIPLES    OF    PLASTIC    SURGERY       83 


incisions  can  be  carried  to  the  other  side  and  above  or 
below  the  defect,  as  shown  in  Figs.  57  and  58. 


FIG.  59. 
TRIANGULAR  EXCISION. 


FIG.  60. 
COAPTATION  OF  P  LAP. 


For  triangular  areas  the  curved  incisions  can  be 
made,  as  in  Fig.  59,  rotating  the  flap  into  place,  as  shown 
in  Fig.  60. 

Or  bilateral  flaps  may  be  utilized  by  straight  incisions, 
stretched  and  sewn,  as  in  Figs.  61  and  62. 


T  T  T  T  i  T  T  T  T 


FIG.  61. 
TRIANGULAR  EXCISION. 


FIG.  62. 
COAPTATION  OF  FLAPS. 


Again,  two  curved  incisions  are  made  to  obtain  rotat- 
ing flaps,  Fig.  63,  and  sewn,  as  shown  in  Fig.  64. 

Biirow  introduced  a  method  for  closing  over  defects 
by  sliding  flaps  in  which  he  utilized  the  mobility  of  skin 
obtained  by  the  excision  of  triangles  of  healthy  skin. 


FIG.  63. 
TRIANGULAR  EXCISION. 


FIG.  64. 
ARRANGEMENT  OF  FLAPS. 


The  results  are  exceedingly  good,  but,  unfortunately,  the 
sacrifice  of  skin  affects  its  general  use,  inasmuch  as  pa- 
tients can  afford  but  little  loss  of  healthy  skin;  besides, 
there  is  the  objection  of  added  scarring.  The  closing  of 


84       PLASTIC    AND    COSMETIC    SURGERY 


a  triangular  defect  by  Iliis  method  is  shown  in  Figs.  65 
and  60,  in  which  (/  is  the  triangular  defect  and  I)  the  tri- 


V 


FIG.  65. 
DOUBLE  TRIANGULAR  EXCISION. 


\ 

\       \         X        XV 

V 

FIQ.  66. 
COAPTATION  OF  WOUND. 


angle  of  healthy  skin  excised.  The  skin  about  the  inci- 
sions is  dissected  up  and  the  flaps  are  sutured  into  posi- 
tion, as  shown  in  Fig.  66. 


FIG.  67. 
TRI-TRIANGDLAK  EXCISION. 


FIG.  68. 
COAPTATION  OF  WOUND. 


Where  the  triangular  defect  has  a  wide  base,  bilateral 
triangular  sections  of  skin  are  removed  (Fig.  67),  and 
the  flaps  are  coapted,  as  in  Fig.  68. 


T  T   I    T    T  \ 


1     I     1     1      1 


FIG.  69. 

RECTANGULAR-BITRIANGULAR 
EXCISION. 


FIG.  70. 
COAPTATION  OF  WOUND. 


Through  the  sacrifice  of  two  triangles  a  large  oblong 
or  square  defect  may  be  covered,  the  excisions  being 
shown  in  Fig.  69  and  the  suturing  in  Fig.  70. 


PRINCIPLES    OF    PLASTIC    SURGERY       85 


111.  TWISTING  METHOD 

Although  in  several  of  the  above  methods  the  flaps 
are  rotated  and  slightly  twisted,  the  following  are  only 
classified  with  those  under  this  division. 

Where  an  elliptical  defect  is  to  be  obliterated  the 
curved  incision  shown  in  Fig.  71  can  be  satisfactorily 


TTTTiTTTT 


FIG.  71. 
WEBER     METHOD. 


Fio.  72. 

COAPTATION    OF    FLAPS. 


employed,  leaving  but  a  small  area  to  granulate  over. 
The  suturing  is  depicted  in  Fig.  72. 

In  this  the  twisting  of  the  flaps  is  but  little,  while  in 
the  following,  in  which  the  defect  is  of  similar  shape,  the 


T  T  I  T 


\N 


FIG.  73. 
ELLIPTICAL  EXCISION. 


FIG.  74. 
COAPTATION  OF  FLAPS. 


twisting  is  more  apparent;  so  much  so,  that  a  fold  at 
the  root  of  the  flap  may  be  induced  to  some  extent.  The 
excision  and  incisions  are  shown  in  Fig.  73,  and  the 
method  of  bringing  the  parts  together  in  Fig.  74,  leaving 
a  small  area  for  granulation, 


86 


PLASTIC    AND    COSMETIC    SURGERY 


Considerable  twisting  of  flaps  is  shown  in  covering 
triangular  parts  in  Figs.  75  and  76. 


FIG.  75. 
TRIANGULAR  EXCISION. 


FIG.  76. 
COAPTATION  OF  FLAPS. 


In  this  only  a  small  surface  is  left  to  granulate  over, 
while  in  the  following  the  parts  are  entirely  covered. 


FIG.  77. 
TRIANGULAR  EXCISION. 


FIG.  78. 
COAPTATION  OF  FLAPS. 


The  excision  and  incisions  are  shown  in  Fig.  77,  and  the 
method  of  approximation  and  suturing  in  Fig.  78. 


FIG.  79. 

LENTENNER  METHOD. 


FIG.  80. 
COAPTATION  OF  FLAP. 


PRINCIPLES    OF    PLASTIC    SURGERY       87 


In  covering  a  square  area  considerable  twisting  must 
be  resorted  to,  as  shown  in  Figs.  79  and  80,  leaving  a  por- 
tion to  granulate. 


VT    r    r  T4A 


FIG.  81. 
BURNS  METHOD. 


HHH- 


FIG.  82. 
COAPTATION  OF  FLAPS. 


Where  the  area  is  irregular  and  formed  somewhat  as 
in  Fig.  81,  bilateral  incisions  are  made  and  the  flaps 
twisted  into  place  and  sewn,  as  in  Fig.  82. 

IV.     IMPLANTATION  OF  PEDUNCULATED  FLAPS  BY 
BRIDGING 

In  this  method  the  flap  to  be  utilized  in  covering  a  de- 
fect is  taken  from  a  dis- 
tant part  of  the  body, 
as,  for  instance,  from 
the  arm.  The  flap  thus 
taken  at  first  remains 
attached  at  its  distal  end 
to  the  tissue  of  the  arm 
by  a  pedicle,  which  is 
not  severed  until  a  cir- 
culation has  been  estab- 
lished between  the  flap 
and  the  part  of  the  hu- 
man economy  to  which 
its  free  end  has  been 
attached  by  suture,  the 
arm  being  held  in  posi- 
tion in  the  meantime  by 
a  suitable  contrivance, 


as  shown  in  Fig.  83, 


FIG.  83, — TXGLjAcqzzA  HARNESS, 


88        PLASTIC    AND    COSMETIC    SURGERY 

These  pedunculated  flaps,  bridging  over  space,  may 
likewise  be  taken  from  the  forearm,  the  hand,  or  the 
thoracic  region. 

When  thoracic  flaps  are  used  they  may  be  directly 
sewn  at  their  free  ends  to  the  part  to  be  covered,  as,  for 
instance,  in  the  forearm  or  arm,  or  they  are  stitched  to  the 
forearm  to  be  later  transferred  to  another  part  of  the 
body  after  their  circulation  had  become  established. 

The  various  methods  of  the  employment  of  these 
bridging  flaps  will  be  taken  up  individually  in  their  re- 
spective places  farther  on. 

V.     TRANSPLANTATION  OF  NONPEDUNCULATED  FLAPS 
OE  SKIN-GRAFTING 

Where  there  is  loss  of  skin  due  to  injury  or  operative 
procedure  the  parts  may  heal  by  granulation,  but  as  this 
requires  much  time,  and  the  consequent  cicatrice  causes 
considerable  deformity,  the  granulating  or  freshly  made 
wounds  are  covered  with  so-called  detached  skin  flaps  or 
grafts,  when  the  former  methods  of  plastic  surgery  can- 
not be  followed. 

The  methods  employed  in  skin-grafting  may  be  classi- 
fied as :  1,  autodermic ;  2,  heterodermic ;  3,  zoodermic. 

1.  Autodermic,  when  the  grafts  are  taken  from  the 
tissue  of  the  patient. 

2.  Heterodermic,  when  the  grafts  for  the  patient  are 
taken  from  other  persons. 

3.  Zoodermic,  when  the  grafts  for  the  patient  are 
taken  from  the  lower  species. 

The  former  two  classes  may  for  convenience  be  again 
subdivided  into 

1.  (a)  Auto-epidermic. 
(b)  Autodermic. 

2.  (c)  Hetero-epidermic. 
(d)  Heterodermic. 


PRINCIPLES   OF    PLASTIC    SURGERY       89 

The  third  class  will  permit  of  a  great  many  subdivi- 
sions, too  numerous  to  mention,  each  taking  its  name 
from  the  source  of  the  graft. 


1.  Autodennic  Skin-grafting 

a.  Auto-epidermic  Skin-grafting. — The  method  of  covering 
granulation  areas  with  small  circular  pieces  of  de- 
tached skin,  pin  grafts,  was  first  advocated  by  J.  Rev- 
erdin  in  1870.  The  Reverdin  method  is  applicable  to 
healthy  granulating  surfaces  only.  The  small  lentil- 
form  skin  grafts  are  obtained  from  the  arm  or  other 
suitable  part  of  the  body  by  raising  the  superficial 
layer  of  the  skin  with  a  tenaculum  hook  and  cutting 
the  conelike  elevation  off  with  delicate 
scissors.  The  grafts  thus  obtained  con- 
tain the  epiderm  and  corium  and  a 
slight  base  of  the  Malpighian  layer. 
They  are  immediately  transferred, 
without  handling,  to  the  granulating 
surface  and  fixed  by  the  gentle  pres- 
sure of  the  hook  point. 

The  skin  may  be  transfixed  with  an 
ordinary  sewing  needle  and  the  graft 
cut  away  with  a  delicate  flat  knife  or 
razor  blade,  or  scissors  especially  de- 
signed for  the  purpose  may  be  used. 
(See  Fig.  84.) 

A  number  of  these  grafts  are  often  needed  to  cover  a 
defect,  in  which  case  they  are  placed  side  by  side  upon 
the  surface  with  a  little  space  between  their  borders. 
Several  such  operations  may  be  necessary,  as  many  of 
the  grafts  are  liable  to  die  from  malnutrition,  pressure, 
or  defective  cutting. 

The  granulating  surface  to  be  covered  in  this  manner 
must  first  be  cleansed  with  a  weak  sublimate  solution,  fol- 
lowed by  a  sterilized  normal  salt  solution,  When  an  ulcer- 


FIG.  84. — SMITH  SKIN 
GRAFTING  SCISSORS. 


90       PLASTIC    AND    COSMETIC    SURGERY 

ated  or  denuded  surface  requires  skin-grafting,  the  best 
time  to  begin  is  as  soon  as  there  is  evidence  of  the  forma- 
tion of  new  skin  at  the  edges  of  the  wound;  in  other 
words,  when  reparative  action  is  becoming  established. 
This  does  not  apply  to  surfaces  just  denuded  over  healthy 
areas  for  plastic  purposes,  which  should  be  grafted  im- 
mediately. 

The  grafts,  having  been  placed,  are  covered  with  a 
layer  of  very  thin  protective  silk,  or  gutta  percha,  over 
which  a  soft  gauze  or  cotton  dressing  may  be  applied, 
borated  absorbent  cotton  being  most  suitable. 

Thiersch  recommends  the  use  of  gauze  compresses 
saturated  in  the  normal  salt  solution,  which  are  changed 
each  day. 

Another  method  of  covering  the  grafts  is  to  use  per- 
forated silk  or  small  strips  of  the  same  material,  which 
permit  the  dressings  to  absorb  the  excretions  from  the 
wound  and  also  allow  of  the  free  use  of  either  weak  anti- 
septic or  sterile  salt  solutions. 

The  use  of  silk  or  rubber  prevents  the  adhesion  of  the 
grafts,  which  would  otherwise  be  torn  away  by  the  re- 
moval of  dressings,  although  iodoform  gauze  answers 
the  purpose  very  well.  It  can  be  safely  lifted  by  first 
thoroughly  wetting  it  with  the  normal  salt  solution. 

Strips  of  tinfoil,  first  rendered  aseptic  by  immersion 
in  a  1-1,000  sublimate  solution  and  then  dipped  into  ster- 
ilized oil  or  two-per-cent  salicylized  oil,  have  been  recom- 
mended by  Socin.  Goldbeaters'  skin  has  also  been  ad- 
vocated. 

A  method  that  has  proved  of  great  value  in  America 
is  that  of  skin-grafting  in  blood.  In  this  method  the 
grafted  site  is  covered  with  perforated  protective  silk  or 
rubber  tissue,  covered  with  a  thin  layer  of  absorbent  cot- 
ton, or,  better,  several  folds  of  sterilized  gauze,  which 
is  kept  wet  constantly  with  bovinine.  The  latter  undoubt- 
edly is  the  means  of  keeping  life  in  the  grafts  by  supply- 
ing the  necessary  nutrition  until  the  grafts  have  formed 


PRINCIPLES    OF    PLASTIC    SURGERY       91 

vascular  connection,  have  become  firmly  adherent,  and 
begin  to  spread  or  grow  out  at  their  edges. 

The  living  grafts  remain  as  pale  islets  of  skin,  which 
throw  out   thin   epidermal   films   that   meet   and   grow« 
thicker,  until  finally  the  inter  joined  grafts  assume  all  the 
functions  of  normal  skin. 

It  is  often  necessary  to  reduce  or  scarify  the  edges 
of  the  healthy  skin  that  has  become  thickened  where  the 
grafts  meet  it.  This  is  permissible  only  when  the  grafts 
have  become  firm  and  thrive,  and  may  be  accomplished 
by  the  careful  and  intelligent  use  of  pure  carbolic  acid 
applied  with  a  wooden  pick,  or  by  the  employment  of  a 
stick  of  fused  nitrate  of  silver,  care  being  taken  not  to 
come  in  contact  or  to  allow  the  cauterant  to  touch  directly 
or  in  solution  the  new  skin. 

b.  Autodermic  Skin-grafting. — Larger  pieces  of  skin  may 
be  excised  from  selected  parts  of  the  body,  preferably  the 
outer  side  of  the  arm,  and  utilized  to  cover  the  entire  de- 
fect. The  piece  of  skin  is  cut  about  one  third  larger  than 
the  size  and  shape  of  the  area  to  be  covered.  This 
method  was  first  introduced  by  R.  Wolfe  in  1876,  and 
gives  splendid  results.  He  advises  removing  all  subcu- 
taneous adipose  tissue  from  the  graft  by  gently  cutting 
it  away  with  fine  scissors  or  the  razor,  and  then  loosely 
suturing  the  flap  to  the  skin  surrounding  the  denuded 
defect. 

Granulating  surfaces  must  first  be  freed  of  their  loose 
superficial  layers  with  a  sharp  curette  and  the  bleeding 
controlled  by  sponge-pressure  before  the  flaps  are  placed. 
The  edges  of  the  wound  made  by  the  excision  of  the  flap 
are  simply  sewn  together,  or  one  of  the  plastic  methods 
may  be  used  to  accomplish  the  same.  Unfortunately 
these  flaps,  if  they  thrive,  contract,  leaving  uncovered 
spaces,  which  must  be  treated  separately  or  allowed  to 
granulate.  The  dressing  in  this  case  is  the  same  as  in  the 
Reverdin  process. 

F.  Krause,  of  Altoona  (1896),  advocates  the  use  of 


92       PLASTIC    AND    COSMETIC    SURGERY 

freed  flaps  from  which  the  subcutaneous  adipose  tissue 
has  not  been  removed,  holding  that  in  the  healing  of  such 
there  is  less  contraction  to  follow.  The  success  in  both 
•of  the  above  methods  depends  upon  an  early  vascular 
connection,  as  considerable  nutrition  is  necessary  to  sup- 
ply their  want.  The  blood  dressing  has  aided  much  in 
bringing  about  a  happy  result.  The  latter  is  continued 
in  the  manner  described  for  about  ten  or  twelve  days, 
when  the  grafts  may  be  allowed  to  depend  upon  their 
own  circulatory  supply.  The  parts  must,  in  the  mean- 
time, be  kept  at  rest  and  all  undue  pressure  is  to  be 
avoided. 

These  grafts,  while  becoming  organized,  change  in 
color  more  or  less  from  a  light  gray  to  a  bluish  gray  and 
shed  off  their  epitheliar  layers,  while  the  cutis  vera  re- 
mains, rebuilding  its  squamous  covering  eventually  and 
leaving  the  surface  quite  normal. 

At  times  small  points  of  the  flap,  where  subjected  to 
undue  pressure  or  interference,  will  turn  dark  and  break 
down,  sloughing  away  and  leaving  the  granulating  sur- 
face exposed.  These  areas  are,  however,  soon  recovered 
by  skin  cells  being  thrown  out  from  the  infral  edges  of 
the  graft.  Often  the  use  of  the  nitrate-of-silver  stick,  ap- 
plied gently  at  various  tardy  points,  will  hasten  the 
process  of  repair. 

The  most  satisfactory  results  in  skin-grafting  are 
those  obtained  by  the  method  introduced  by  Oilier,  of 
Lyons,  in  1872,  and  perfected  by  Thiersch,  of  Leipzig, 
1874.  His  method  is  now  almost  entirely  used  for  cov- 
ering large  defects.  The  grafts  can  be  applied  over  con- 
nective tissue,  periosteum,  bone,  and  even  adipose  tissue. 
The  grafts  consist  of  very  thin  strips  of  skin  taken  from 
the  extensor  surface  of  the  arm  or  the  anterior  region 
of  the  thigh,  after  thorough  antiseptic  preparation.  They 
should  be  taken  from  the  patient  in  preference  to  those 
of  other  individuals  or  the  new-dead  or  freshly  ampu- 
tated parts. 


PRINCIPLES    OF    PLASTIC    SURGERY       93 

Granulating  surfaces  are  scraped  clean  of  their  su- 
perficial or  loose  layer,  while  fresh  wounds  may  be  cov- 
ered at  once  or  a  few  days  after  having  been  made, 
antiseptic  compresses  being  used  in  the  meantime.  Hem- 
orrhage is  controlled  at  the  time  of  grafting  by  sponge- 
pressure  or  torsion  of  the  small  vessels. 

In  this,  as  in  the  former  method,  it  is  desirable  that 
the  surface  to  be  covered  be  free  from  loose  tissue  and 
dry  (Gar re). 

For  the  removal  of  the  strips  the  Thiersch  razor  is  to 
be  used.  It  is  concave  on  its  upper  side  and  plane  below, 
the  blade  being  bent  at  an  angle  to  the  handle  (Fig.  85). 


FIG.  85. — THIERSCH  RAZOR. 

Folding  razors  of  the  same  type  can  be  procured;  their 
advantage  lies  in  having  a  protecting  case  when  not 
in  use. 

Slide  fixation  locks  are  a  valuable  addition  to  the  lat- 
ter, as  they  hold  the  blade  in  place  when  open.  See 
Fig.  86. 


FIG.  86. — FOLDING  RAZOR. 


The  site  from  which  the  graft  is  to  be  taken  is  first 
thoroughly  scrubbed  and  washed,  then  cleansed  with  an 
antiseptic  solution.  The  skin  of  the  anterior  surface  of 
the  arm  or  upper  thigh  is  usually  chosen.  The  skin  of 
the  part  is  made  tense  with  the  left  hand,  while  the  point 
of  beginning  is  slightly  raised  by  the  assistant  with  the 
aid  of  a  tenaculum  hook.  The  razor,  dipped  into  sterile 
salt  solution,  is  now  taken  in  the  right  hand  and  by  quick 


94       PLASTIC    AND    COSMETIC    SURGERY 

sawing  movements,  the  plane  side  being  placed  next  to 
the  limb,  a  strip  of  skin  is  detached  (Fig.  87),  which,  as 
it  is  cut,  glides  in  folds  upon  the  concave  side  of  the 
razor. 

The  uppermost  layer  of  the  skin  is  removed,  including 
epidermis,  the  Malpighian  and  papillary  layers,  as  well 
as  a  small  portion  of  the  stroma.  Hubsclier  includes  only 
the  epidermis  and  the  upper  portion  of  the  papillary 
layer,  with  equal  success. 

The  length  and  width  of  the  strips  so  removed  must 
be  made  according  to  the  defect  to  be  covered.  Their 


Fia.  87. — METHOD  OF  CUTTING  THIERSCH  GRAFT. 

width  may  be  made  as  much  as  two  inches  and  their 
length  not  to  exceed  four  inches. 

The  collected  strip  of  skin,  still  on  the  razor,  is  now 
brought  to  the  place  of  grafting  and,  with  the  point  of  a 
needle  placed  at  its  farther  end,  is  slid  off  upon  the  part 
to  be  covered  and  allowed  to  fall  in  place  by  the  gentle 
backward  withdrawal  of  the  razor  blade,  as  shown  in 
Fig.  88. 


PRINCIPLES    OF    PLASTIC    SURGERY       95 

The  graft  may  be  smoothed  out  with  the  needle  held 
flatwise  or  be  stroked  down  gently,  so  that  its  fresh  sur- 
face makes  contact  with  every  portion  of  the  part  cov- 


FIG.  88. — METHOD  OF  PLACING  THIERSCH  GEAFTS. 

ered,  a  precaution  the  author  considers  important  to 
obtain  the  best  results. 

If  the  defect  is  large,  and  where  several  grafts  are 
needed,  the  second  flap  thus  obtained  is  made  to  slightly 
overlap  the  one  already  placed,  and  so  on.  The  free,  or 
distal,  ends  of  the  flaps  are  made  to  slightly  overlap  the 
skin  or  that  of  a  graft  placed  endwise  to  it.  Every  part 
of  the  wound  should  be  covered. 

As  soon  as  this  has  been  accomplished  the  strips  are 
powdered  over  with  iodol  or  aristol  or  protected  with 
some  antiseptic  gauze  (boric  or  iodoform),  or  covered 
with  strips  of  lint  smeared  with  borated  petrolatum,  over 
which  light,  teased-out  pieces  of  sterilized  cotton  are 
placed.  A  gauze  bandage  may  be  utilized  to  hold  all 
in  place. 

It  is  quite  necessary  to  have  the  part  kept  at  rest  so 
as  not  to  displace  the  skin-graft  arrangement.  If  the 


96       PLASTIC   AND    COSMETIC    SURGERY 

antiseptic  powder  has  been  used  the  dressings  need  not 
be  disturbed  for  a  week  or  ten  days,  but  the  petrolatum 
dressing  must  be  changed  every  third  day,  care  being  ob- 
served not  to  disturb  the  grafts. 

Perhaps  the  best  success  is  obtained  by  the  aid  of  per- 
forated rubber  tissue,  covered  with  gauze  dressing,,  con- 
stantly kept  wet  with  bovinine  for  ten  days. 

In  healing,  parts  of  the  grafts  may  die,  leaving  small 
areas  to  granulate  over,  but  ordinarily  the  cicatrization 
resulting  therefrom  is  indeed  slight.  From  the  observa- 
tions of  E.  Fisher,  it  seems  that  the  most  successful  re- 
sults are  obtained  when  the  grafts  are  taken  and  trans- 
planted under  the  bloodless  method  of  Von  Esmarch. 

2.  Heterodermic  Skin-grafting 

c.  Hetero-epidermic    Skin-grafting. — A    novel    method    of 
covering  wounds  with  skin  is  advocated  by  Z.  J.  Lusk,  of 
Warsaw,  N.  Y.,  1895,  in  which  small  squares  of  epithelium, 
previously  prepared,  are  placed  upon  the  granulating 
surface,   over  which  a  dressing  of   sterilized  gauze  is 
placed,  saturated  with  a  mixture  of  balsam  of  Peru,  5j, 
and  ol.  Ricini,  §j,  and  covered  with  several  layers  of  ster- 
ilized absorbent  cotton.    The  dressing  is  allowed  to  re- 
main undisturbed  until  the  tenth  or  twelfth  day,  unless 
there  is  an  accumulation  of  pus. 

The  advantage  of  this  method  is  that  the  epidermal 
layers  can  be  collected  at  random  from  various  patients 
who  present  themselves  with  blistered  surfaces — the  re- 
sult of  burns — or  where  the  skin  has  been  raised  by  some 
blistering  process  for  counterirritative  reasons. 

This  loose  skin  is  collected  and  spread  upon  a  glass 
plate  and  sterilized  in  warm  boric-acid  solution,  then 
allowed  to  dry  in  this  position  to  prevent  curling,  and, 
when  dry,  cut  into  desirable  sizes  and  laid  away  for 
future  use. 

d.  Heterodermic  Skin-grafting. — In  this  mode  of  skin-graft- 
ing the  pieces  of  skin  are  taken  from  freshly  ampu- 


PRINCIPLES   OF    PLASTIC    SURGERY       97 

tated  limbs  of  one  patient  or  from  any  selected  part  of 
the  body  of  the  newly  dead,  and  placed  upon  the  defects 
to  be  covered  in  another  patient.  These  grafts  have 
been  successfully  employed  even  after  ninety-six  hours 
had  elapsed  between  the  time  of  amputation  or  the  death 
of  a  person  and  the  taking  of  the  skin-grafts. 

The  method  employed  is  as  follows:  The  site  of  the 
amputated  member  or  dead  body  from  which  the  skin  is 
to  be  taken  is  thoroughly  cleansed,  as  in  the  Thiersch 
method.  Pieces  of  the  skin,  including  the  subcutaneous 
tissue,  but  no  fat,  are  cut  from  the  cleansed  parts.  These 
sections  are  cut  into  smaller  pieces,  about  one  inch 
square  (Hartman  and  Weirick),  and  placed  upon  the 
granulating  surface  to  be  covered,  leaving  one-half-inch 
wide  interval  between  each  piece. 

The  grafts  are  then  covered  with  overlapping  narrow 
strips  of  rubber  tissue,  over  which  a  normal  saline  dress- 
ing is  applied.  The  outer  dressing  is  composed  of  gauze 
saturated  with  the  same  solution.  These  dressings  are 
changed  every  twenty-four  hours. 

The  grafts  will  soon  be  found  to  adhere,  showing  a 
pinkish  color  in  about  six  days;  those  showing  a  tendency 
to  undergo  gangrene  or  a  laziness  of  attachment  at  this 
time  are  removed. 

In  about  two  weeks  the  epitheliar  surfaces  of  these 
grafts  are  thrown  off,  as  with  other  grafts  already  men- 
tioned, and  shortly  thereafter  a  new,  deep-pink  epithe- 
lium is  formed,  the  ends  of  the  grafts  throw  out  epitheliar 
cells,  which  soon  coalesce  with  those  of  the  neighboring 
grafts,  eventually  taking  on  the  normal  appearance  and 
vitality  of  skin. 

3.  Zoodermic  Skin-grafting 

The  advantage  of  using  zoodermic  grafts  is  that  the 
patient  is  saved  the  ordeal  of  general  anesthesia  and  the 
secondary  wound  occasioned  by  the  removal  of  the  graft, 
which  necessarily  leaves  more  or  less  of  a  scar. 


The  grafts  for  this  purpose  may  be  taken  from 
freshly  killed  animals,  such  as  dogs,  rabbits,  frogs,  kit- 
tens, etc. 

The  best  results,  in  the  estimation  of  the  author,  are 
obtained  by  the  use  of  the  skin  taken  from  the  abdominal 
region  of  dogs. 

The  method  for  preparing  these  grafts  is  to  kill  a 
healthy  animal,  thoroughly  cleansing  the  skin  of  the  ab- 
domen, as  already  described  in  the  taking  of  any  graft. 

The  entire  abdominal  surface  is  neatly  shaved  under, 
antiseptic  precautions  and  the  skin  is  dissected  off  in 
one  piece,  leaving  the  subcutaneous  tissue.  It  is  then 
placed  in  a  warm  boric-acid  solution  and  cut  into  small 
pieces,  say  one  or  two  inches  square,  according  to  the 
size  of  the  defect  to  be  covered. 

These  pieces  are  placed  upon  the  granulating  surface 
and  firmly  pressed  into  place,  so  that  they  are  in  close 
contact  throughout  their  area.  Other  pieces  are  placed 
quite  near  or  even  in  contact  with  the  edge  of  the  first, 
and  so  on,  until  the  space  is  entirely  covered.  Boric-acid 
dressing  of  any  desired  form  is  placed  over  them  and 
superimposed  by  loose  gauze  and  bandage. 

The  dressing  should  be  left  undisturbed  for  at  least 
forty-eight  hours,  and  then  be  gently  removed  and  re- 
newed. The  utmost  care  should  be  exercised  with  the 
dressings,  since  here  lies  the  success  of  the  whole  result. 
The  blood  dressings  have  given  excellent  results  in  cases 
undertaken  by  the  author,  and  should  be  resorted  to 
whenever  practicable.  The  method  has  already  been  fully 
described,  and  does  not  differ  in  the  event  of  employing 
zoodermic  grafts. 

When  boric-acid  dressings  are  used,  they  should  be 
changed  every  day  after  the  first  dressing  has  been  re- 
moved, so  that  the  behavior  of  the  grafts  can  be  closely 
watched. 

Lazy  grafts  and  those  showing  signs  of  sloughing 
should  be  removed  at  once,  and  granulations  crowding 


PRINCIPLES   OF   PLASTIC    SURGERY       99 

through  the  grafts  should  be  snipped  off  with  a  fine  scis- 
sors, as  they  are  liable  to  destroy  the  life  of  a  graft 
by  pressure  or  by  crowding  it  away  from  its  bed  of 
nourishment. 

As  in  dermic  grafts,  the  upper  layers  of  these 
plaques  will  be  thrown  off,  giving  at  times  the  appear- 
ance of  total  sloughing,  yet  on  interference  the  deeper 
layers  will  be  found  to  be  intact  and  healthy.  The  dress- 
ings should  be  continued  until  the  grafts  have  not  only 
established  their  circulation,  but  until  their  edges  have 
firmly  united  and  the  surface  has  taken  on  a  dull  reddish 
color,  which  eventually  fades  to  a  shade  somewhat  paler 
than  the  normal  skin.  The  hairs  that  have  been  car- 
ried over  with  the  grafts  at  first  seem  to  thrive,  but 
eventually  drop  out,  leaving  the  surface  bare.  Spots 
of  color  so  often  observed  in  the  skin  of  the  bellies  of 
dogs  also  disappear  from  the  grafts,  leaving  their  color 
uniform. 

Amat,  in  1895,  claims  that  good  results  in  skin-graft- 
ing are  obtained  by  substituting  the  epidermal  pin  grafts 
with  the  film  or  inner-shell  lining  membrane  of  the  fresh 
hen's  egg.  For  this  purpose  as  fresh  an  egg  as  can  be 
obtained  is  used.  It  is  broken  along  the  horizontal  axis. 
A  delicate  forceps  is  now  made  to  grasp  the  free  mem- 
brane found  at  the  air  chamber  of  the  enlarged  end  of 
the  egg.  The  inner  lining  is  drawn  away  from  the  shell 
in  pieces  four  or  five  millimeters  long;  these  pieces  are 
cut  with  a  fine  scissors  into  equal  lengths  and  placed  with 
the  point  of  the  scissors  to  the  granulating  surface  to  be 
covered,  in  the  same  way  as  the  Reverdin  grafts.  Amat 
covered  the  grafts  with  tinfoil,  over  which  were  placed 
several  lays  of  carbolized  gauze.  The  dressings  were 
changed  every  three  or  four  days. 

The  skin  of  the  frog  has  successfully  been  implanted 
upon  granulating  surfaces  by  Baratoux  and  Dobousquet- 
Laborderie.  They  observed  that  the  peculiar  pigmented 
mottling  of  the  skin  disappeared  about  the  tenth  day,  and 


100      PLASTIC   AND    COSMETIC    SURGERY 

that  the  grafts  gradually  took  on  the  appearance  of  hu- 
man skin  thereafter. 

The  best  results  in  this  method  are  obtained  with  the 
skin  taken  from  the  back  of  the  frog  in  preference  to  that 
of  the  belly  or  legs.  This  skin  is  cut  into  pieces  about 
one  fourth  inch  square,  which  are  placed  upon  the  granu- 
lating surface  in  rows,  each  graft  being  separate  from 
its  neighbor  by  a  space  of  half  an  inch. 

At  the  end  of  forty-eight  hours  the  plaques  of  skin 
will  have  adhered  to  the  granulating  surface.  At  the  end 
of  five  days  they  lose  their  original  color  and  send  out 
cells  of  epithelium  to  each  neighboring  square. 

The  dressing  to  be  applied  over  the  flaps  should  con- 
sist of  borated  vaselin,  one  dram  to  the  ounce,  which  is 
smeared  upon  strips  of  sterile  gauze,  over  which  loose 
gauze  is  placed,  held  in  place  by  a  roller  bandage. 

The  skin,  once  organized,  is  very  thin,  as  a  rule,  and 
requires  more  or  less  care  for  some  time  after. 

General  Remarks 

The  skin  of  the  grafted  area  will  alwaj^s  present  a  dif- 
ferent appearance  from  that  of  the  healthy  skin,  both  as 
to  color,  which  is  always  paler,  and  in  texture.  The 
grafted  portion  is  usually  slightly  elevated  above  the 
healthy  skin,  giving  it  an  edematous  look. 

It  has  been  found  that  skin  grafts  taken  from  the  negro 
take  more  successfully  than  those  from  the  white  race. 
White  skin  flaps  placed  upon  the  negro  do  not  meet  with 
much  success.  In  this  event,  however,  the  newly  grafted 
skin  soon  takes  on  the  color  peculiar  to  the  negro  and 
vice  versa  (Thiersch). 

The  investigations  of  Karg  seem  to  show  that  the 
pigmentation  of  skin  is  not  secreted  in  the  rete,  but  is 
carried  to  it  by  wandering  cells  arising  from  the  deeper 
layer.  Von  Altmann  has  discovered  certain  cell  gran- 
ules, termed  by  him  bioblasts,  which  he  believes  are  re- 


PRINCIPLES    OF    PLASTIC    SURGERY      101 

sponsible  for  the  production  of  the  pigmentary  deposits 
under  peculiar  influences  of  the  blood. 

MUCOUS-MEMBRANE-GRAFTING 

The  grafting  of  mucous  membrane,  both  from  the  ani- 
mal and  man,  has  been  accomplished  by  Wolfler.  His 
methods  are  particularly  applicable  to  the  restoration 
of  the  conjunctiva,  mucous  membrane  of  the  cheek,  etc. 
Under  certain  circumstances  pedunculated  skin  flaps 
have  been  folded  inward  to  serve  as  the  mucous  mem- 
brane by  Gersuny.  When  mucous-membrane  flaps  were 
taken  from  the  animal,  the  conjunctiva  of  the  rabbit  has 
been  preferred. 

Under  peculiar  circumstances,  though  rarely,  mucous- 
membrane  flaps  may  be  utilized  to  cover  denuded  skin 
areas.  The  mucous  membrane,  in  such  cases,  in  about 
ten  days  takes  on  the  appearance  of  the  skin. 

Ofttimes,  when  it  is  impossible  to  obtain  foreign  mu- 
cous membrane,  grafts  may  be  taken  from  the  inner  sur- 
face of  the  lips  of  the  patient.  These  grafts  answer 
exceedingly  well  for  conjunctival  restorations,  while  the 
wound  occasioned  by  their  removal  is  closed  by  suture  or 
allowed  to  heal  by  itself,  if  not  too  large,  under  boric- 
acid  antisepsis. 

BONE-GRAFTING 

Bone-grafting,  as  followed  by  MacEwen,  Oilier,  Pon- 
cet,  and  Adamkierwicz,  has  been  more  or  less  successful. 
Their  methods  have  been  often  employed  in  plastic  facial 
surgery,  as  will  be  shown  later.  Their  methods  were  later 
improved  by  Senn,  who  advocated  chips  of  decalcified 
bone  in  place  of  bone  taken  from  young  or  new-born  ani-  • 
mals,  from  which  the  bones  under  ossification  have  been 
utilized. 

Gliick's  method  of  introducing  pieces  of  ivory  into 
bone  defects  may  be  of  interest,  but  is  applicable  only  to 


102     PLASTIC   AND    COSMETIC    SURGERY 

long  bone  implantations.  The  success  of  his  method  has 
yet  to  be  practically  demonstrated.  Zahn  and  Fisher 
have  used  various  foreign  substances  to  overcome  bone 
defects,  but  these  do  not  interest  the  cosmetic  surgeon  to 
any  extent,  since  other  methods  have  been  proved  to  give 
better  results.  These,  however,  belong  to  the  subject  of 
subcutaneous  prothesis,  and  must  be  considered  sepa- 
rately thereunder. 

HAIR-TRANSPLANTATION 

It  may  be  of  interest  to  know  that  Schweininger  and 
v.  Nussbaum  have  attempted  to  graft  hairs  upon  granu- 
lating tissue  by  sprinkling  the  hairs,  with  their  attached 
roots,  upon  the  surface  to  be  covered.  If  any  of  these 
lived  and  attached  themselves  the  root  sheath  formed  a 
scar  center,  and  the  hair  dropped  out  after  several  days. 


CHAPTER   IX 
BLEPH  AEOPL  AS  T  Y 

(Surgery  of  the  Eyelids) 

PLASTIC  operations  about  the  eyelids  are  necessitated 
by  and  for : 

I.  Direct  injury  causing  the  loss  of  a  part,  one  or 

both  lids. 
II.  Loss  of  tissue  following  excision  of  tumor. 

III.  Loss  of  tissue,  the  result  of  gangrene  or  ulcera- 

tion. 

IV.  Injuries  due  to  burn  or  acid  wounds. 

V.  The  healing  and  cicatrization  following  lupus. 
VI.  The  cicatrization  following  inflammatory  lesions 
of  the  orbital  borders,  especially  those  of  the 
supra-orbital  ridge.    Since  the  upper  lid  lies  be- 
low the  supra-orbital  ridge,  the  above  cause  is 
rarely  met  with. 
VII.  For  the  removal  of  redundant  tissue. 

The  result  of  the  above  causes  leads  to  eversion  of  the  lid 
(ectropion).  There  may  be  cicatricial  contraction  of  the 
conjunctiva  leading  to  ectropion,  however,  but  its  cor- 
rection is  not  strictly  of  a  plastic  nature  and  belongs 
principally  to  the  oculist  surgeon,  and  will  therefore  not 
be  referred  to  herein. 

ECTROPION 

Ectropion  is  not  uncommon,  and  involves  the  lower 
lid  only  in  the  great  majority  of  cases.    It  may  be  par- 

103 


104      PLASTIC   AND    COSMETIC    SUEGEEY 


tial  or  complete,  according  to  the  extent  of  cicatricial 
changes  in  the  skin. 


a.  >. 

FlG.    89. DlEFFENBACH    METHOD. 


PAETIAL  ECTROPION 

For  the  correction  of  partial  ectropion  a  V-shaped 

incision  is  made 
on  the  lid  with  the 
base  of  the  trian- 
gle, including  the 
maximum  ever- 
sion,  as  in  Fig. 
89,  a. 

The  incisions 
are  made  down- 
ward from  the 
tarsal  border,  just 
below  the  lashes, 
and  converge  to  a 
point.  The  flap 
included  therein 
is  carefully  dis- 
sected up,  divid- 

Fia.  90a.— CORRECTION  OF  PARTIAL  ECTROPION.         1D&       . 

(Author's  case.)  adhesions,  and  is 


BLEPHAROPLASTY 


105 


pushed  upward  until  the  tarsal  border  at  the  seat  of  the 
defect  is  overcorrected  in  this  position.  The  incisions 
are  united  with  No.  1  twisted-silk  structures  to  form  the 
letter  Y,  as  shown  _ 
in  Fig.  89,  b. 

As  the  lid  has 
usually  become 
elongated  from 
prolonged  ever- 
sion,  a  small,  tri- 
angular piece  of 
skin  may  be  ex- 
cised at  the  outer 
end  of  the  lid, 
with  its  base 
turned  upward. 
In  bringing  the 
two  sides  togeth- 
er in  linear  form, 
horizontal  trac- 
tion is  made  along 
the  tarsal  line, 
which  aids  much 
in  bringing  about 
the  desired  result. 

In  the  case  shown  in  Fig.  9Qa  the  ectropion  was  the 
result  of  the  application  of  nitric  acid  or  caustic  potash 
for  the  removal  of  a  nevus.  It  was  corrected  by 
ihe  method  just  described,  the  result  being  shown  in 


FIG.  906. — CORRECTION  OF  PARTIAL  ECTROPION. 
(Author's  case.) 


Fig. 


COMPLETE  ECTROPION 


Dieffenbach  Method.  —  In  complete  ectropion  the  entire 
lid  between  the  canthi  is  included  in  the  V-shaped  inci- 
sion just  mentioned  (Fig.  91)  and  the  flap  is  sutured  as 
shown  in  Fig.  92. 

In  crowding  up  the  detached  flap  the  palpebral  bor- 


106      PLASTIC    AND    COSMETIC    SURGERY 


der  must  be  overcorrected,  since  the  contractions  follow- 
ing union  will  reduce  the  effect  even  to  the  extent  of 
necessitating  later  minor  operations. 


FIG.  91.  FIG.  92. 

COMPLETE  ECTROPION,  DIEFFENBACH  METHOD. 

To  prevent  this  contraction  the  palpebral  fissure  may 
be  united  after  the  correction  is  made  by  fine  sutures, 
which  are  removed  in  several  weeks  (Plessing).  This  is 
rather  uncomfortable  for  the  patient,  but  there  is  no 
question  as  to  the  efficacy  of  the  method.  A  shield  can 
be  worn  over  the  eye  operated  upon  after  the  incisions 
have  united  until  the  lids  are  separated.  This  relieves 
the  discomfort  of  the  patient  to  some  extent,  while  the 
constant  conscious  strain  to  open  the  eye  is  greatly  over- 
come by  the  mere  knowledge  of  the  presence  of  the  shield. 

If  the  position,  or  the  extent  of  the  deformity,  does 
not  permit  of  the  Dieffenbach  method,  the  following  may 
be  employed: 

Wolfe  Method. — An  incision  is  made  parallel  to  the  tar- 
sal  border  just  below  the  lashes.  The  scar  tissue  is  then 
excised.  The  palpebral  fissure  is  closed  by  several  su- 
tures, as  already  described,  thus  drawing  up  the  everted 
portion  and  bringing  the  lids  together  and  causing  a 
large,  open  wound  (Fig.  93). 


BLEPHAROPLASTY 


107 


After  the  hemorrhage  has  been  controlled  a  piece  of 
skin  about  one  third  larger  than  the  defect  is  taken  from 
the  arm  or  temporal  region  of  the  patient.  Next  its  re- 
verse side  is  freed  of  all  adipose  tissue.  It  is  then  laid 
upon  the  freshly  made  open  wound,  covering  it  com- 
pletely, and  held  in  place  by  numerous  fine  silk  sutures 
fixing  it  along  the  wound  margin,  as  shown  in  Fig.  94. 


FIG.  93 


FIG.  94. 


WOLFE  METHOD. 


There  is  more  or  less  contraction  of  the  flap,  although 
primary  union  takes  place.  Less  contraction  of  the  flap 
is  obtained  in  the  Wolfe  method  when  the  subcutaneous 
fat  is  not  removed,  as  mentioned  above  (Hirschberg). 

Thiersch  Skin-grafting  Method. — To  somewhat  overcome 
the  contraction  of  the  single-graft  operation  of  Wolfe,  the 
Thiersch  skin-grafting  method  may  be  resorted  to  as 
already  described.  Better  results  have  been  obtained 
with  this  method.  The  graft  should  be  placed  parallel 
to  the  tarsal  border.  A  number  of  Beverdin  grafts  can 
be  taken  from  the  temporal  region,  just  below  the  hair 
line,  and  used  to  cover  the  wound.  These  small  grafts 
must  be  placed  quite  close  together  to  obtain  the  best 
result  (Von  Wecker).  Immobility  of  the  lid  is,  of  course, 
necessary,  and  the  temporary  fixation  of  the  lid  must  be 
accomplished  as  already  described.  Contraction  in  this, 


108      PLASTIC    AND    COSMKTIO    SURGERY 

as  in  any  other  skin-grafting  methods,  is  to  be  looked  for 
and  remedied  later  by  minor  plastic  operations. 

Fricke's  Method. — The  best  results  in  blepharoplasty, 
after  the  extirpation  of  tumors,  are  undoubtedly  obtained 
by  Fricke's  method.  A  flap  is  obtained  from  the  tem- 
poral region,  with  its  base  in  line  with  the  inferior  border 
of  the  defect  to  be  covered.  The  flap  must  be  cut  to  about 
twice  the  size  of  the  bared  surface,  because  of  the  con- 
traction that  follows  in  healing,  and  also  to  permit  of 
covering  the  defect  in  its  longest  diameter  when  twisted. 


FIG.  95.  FIG.  96. 

FRICKE  METHOD. 

The  flap  should  be  taken  from  the  tissues  at  the  outer 
angle  of  the  eye  and  cut  in  the  curved  form  depicted  in 
Fig.  95  to  overcome  its  distortion  as  much  as  possible  in 
twisting.  It  is  twisted  upon  its  pedicle  at  an  angle  of  90° 
and  sutured  into  the  defect,  as  shown  in  Fig.  96. 

The  lids  are  temporarily  sewed  together,  thus  stretch- 
ing the  defect  fully  into  which  the  flap  is  to  be  sutured. 
The  pedicle  is  severed  after  thorough  circulation  in  the 
flap  has  been  established. 

Owing  to  the  free  movement  of  the  skin  over  the  tem- 
poral fascia,  the  wound  formed  by  the  incision  of  the  flap 
can  be  entirely  closed  by  a  single  line  of  interrupted 
sutures. 

Ammon  and  Von  Langenbeck  Method. — A  very  similar 
method,  especially  devised  for  the  correction  of  extensive 
ectropion  of  the  lower  lid,  is  that  in  which  the  peduncu- 
lated  flap  is  taken  from  the  latter  aspect  of  the  cheek. 


BLEPHAROPLASTY 


109 


A  curved  incision  is  made  just  below  the  tarsal  border, 
freely  loosening  the  attached  conjunctiva  in  this  manner. 
The  cicatricial  tissue  or  other  cause  of  the  defect  is  thor- 
oughly excised  and  the  lids  fixed  together  by  suture. 


FIG.  97.  FIG. 

AMMON-VON  LANGENBECK  METHOD. 

The  wound  is  then  fully  exposed.  A  curved  incision, 
as  shown  in  Fig.  97,  is  now  made,  with  its  base  in  line 
with  the  superior 'line  of  the  raw  surface.  It  is  carefully 
dissected  up  and  twisted  into  position  and  held  by  su- 
ture (Fig.  98). 

The  sides  of  the  wound  made  by  the  excision  of  the 
flap  are  brought  together  by  an  interrupted  suture. 

The  skin  of  the  cheek  is  liable  to  contract  more  read- 
ily than  that  from  the  temporal  region,  because  it  is 
thicker.  Again,  it  is  less  suitable  for  grafting  because 
of  its  subcutaneous  layer  of  adipose  tissue. 

Dieffenbach-Serre  Method. — Where  the  defect  is  too  large 
to  be  covered  with  any  of  the  preceding  methods, 
as  is  often  the  case  following  the  extirpation  of  car- 
cinomata,  a  rhomboid  flap  can  be  utilized  as  shown  in 
Fig.  99. 

The  extirpation  incision  is  made  in  the  form  of  a  V. 
The  faulty  tissue  or  scar  is  removed,  care  being  exer- 
cised to  retain  as  much  of  the  conjunctiva  as  possible. 


110      PLASTIC   AND    COSMETIC    SURGERY 


A  rhomboid  flap  is  then  taken  from  the  lateral  aspect  of 
the  cheek  and  slid  over  the  defect  and  sutured  into 
place,  as  shown  in  Fig.  100. 

The  objection  to  this  method  is  that  the  extensive 
contraction  following  the  healing  of  the  wound  made  by 


FIG.  99.  FIG.  100. 

DIEFFENBACH-SERRE  METHOD. 

the  raising  of  the  flap  causes  the  lid  to  be  drawn  outward. 
This  wound  is  usually  allowed  to  heal  by  granulation, 
but  it  is  better  to  place  Thiersch  grafts  over  the  area 
which  cannot  be  closed  by  suture,  either  immediately  or 
as  soon  as  a  good  granulating  surface  has  been  obtained 
and  the  sutured  portions  have  become  healed. 

The  outer  or  free  margin  of  the  conjunctiva  is  sutured 
to  the  upper  free  border  of  the  rhomboid  flap  or  enough 
of  the  flap  should  be  at  first  provided  by  incision  to  war- 
rant the  turning  in  of  its  superior  or  palpebral  border 
after  it  is  slid  into  place. 

In  such  case,  however,  it  is  best  to  provide  mucous- 
membrane  grafts  from  the  lip  of  the  patient  to  overcome 
the  loss  of  conjunctiva  (Wolfer). 

Because  of  the  splendid  success  obtained  with  tem- 
poral flaps  it  is  better  to  follow  the  method  of  Fricke  in 
the  above  operation,  changing  the  shape  of  the  flap  to  suit 
the  form  of  the  defect  to  be  covered. 


BLEPHAROPLASTY 


111 


Tripier  Method. — For  the  restoration  of  an  entire  lid 
the  method  of  Tripier  is  to  be  advocated.  A  bridge  flap 
with  both  ends  attached  is  taken  from  the  healthy  eyelid 
(Fig.  101).  It  is  obtained  by  making  the  curved  inferior 
incision  in  a  line  with  the  superior  border  of  the  tarsal 
cartilage,  and  the  superior  incision  parallel  to  the  first 
at  a  distance  depending  upon  the  size  of  the  defect 
to  be  covered.  The  flap  thus  formed  should  include 
some  of  the  fibers  of  the  orbicularis  muscles  detached 
from  the  tarsal  cartilage,  making  it  really  musculo- 
cutaneous. 

This  bridge  or  musculo-cutaneous  flap,  attached  at 
both  ends,  is  then  gently  drawn  forward  with  a  tenacu- 
lum  and  slid  downward  over  the  upper  lid  upon  the  de- 
fect of  the  lower  lid,  and  there  retained  by  interrupted 


^  $0* 


FIG.  101. 


FIG.  102. 
TRIPIER  METHOD. 


FIG.   103. 


silk  sutures  (Fig.  102),  the  superior  margin  of  the  bridge 
flap  being  sutured  to  the  conjunctival  fold  freed  by  the 
previous  extirpation  of  the  lower  lid. 

The  retention  of  the  fibers  of  the  orbicularis  palpe- 
brarum  in  the  flap  covering  the  defects  is  intended  to 
take  the  place  of  the  part  of  muscle  destroyed  by  the 
incision  of  the  faulty  tissue  in  the  lower  lid,  and  enables 
the  patient  to  open  and  close  the  lid  almost  as  well  as 
in  the  normal  state. 

The  margins  of  the  wound  made  by  the  removal  of 
the  flap  are  snugly  brought  together  and  heal  without 


112      PLASTIC   AND    COSMETIC    SURGERY 

the  least  discomfort  to  the  patient,  inasmuch  as  the  skin 
covering  the  lid  is  quite  loose  and  elastic  (Fig.  103). 

Von  Artha  Method. — Jt  sometimes  happens  that  by  the 
extirpation  of  tumors  part  of  both  eyelids  has  to  be 
removed.  To  restore  such  defect  the  following  method 
may  be  followed: 

Two  sickle-shaped  flaps  are  raised  from  the  skin  bor- 
dering the  outer  margins  of  the  primary  incision,  ac- 


FIG.  104.  FIG.  105. 

VON  ARTHA  METHOD. 

cording  to  Van  Artha,  and  sliding  them  about  so  as  to 
reform  the  canthus  of  the  palpebral  fissure  (Figs.  104 
and  105). 

This  method  leaves  little  if  any  secondary  effect,  its 
immediate  success  depending  upon  the  preservance  of  the 
conjunctiva  at  the  time  of  extirpation. 

As  will  be  seen,  the  foregoing  method  only  included 
operations  about  the  lower  lid.  The  majority  of  these 
operations  are  required  only  for  the  lower  lid ;  where 
defects  of  the  upper  lid  are  to  be  corrected  the  flaps  and 
incisions  mentioned  must  be  made  to  correspond  to  the 
defect,  while  in  the  V-Y  method  the  incision  must  be 
inverted. 

ECTEOPIOIST  OF  BOTH  LIDS 

In  the  case  of  ectropion  of  both  lids  the  palpebral 
tissue  may  be  sutured  for  a  period  of  several  months  with 
certain  benefit,  if  no  other  operations  can  be  decided  upon. 


BLEPHAROPLASTY  113 

Or  the  method  may  be  combined  with  any  other  plastic 
operation  deemed  serviceable  for  its  correction.  In  most 
defects  of  the  upper  lid,  however,  if  they  are  not  too  ex- 
tensive, the  loose  skin  of  the  lid  itself  can  be  utilized  by 
sliding  flap  methods  to  cover  the  defect  (Kolle). 

EPICANTHUS 

This  condition,  in  which  a  fold  of  skin  stretches  across 
from  the  inner  end  of  the  brow  to  the  side  of  the  nose 
covering  the  inner  canthus,  is  met  with  principally  in 
children.  It  usually  disappears  later  in  life.  It  may  re- 
main, however,  owing  to  nondevelopment  of  the  nasal 
bridge  and  is  often  met  with  in  the  colored  races. 

Bull  Method. — This  defect  may  be  corrected  by  the  ex- 
cision of  an  elliptical  piece  of  skin  from  the  anterior 


FIQ.  106.  FIG.  107. 

BULL  METHOD. 

aspect  of  the  brige  of  the  nose,  and  sewing  the  wound 
together  with  interrupted  fine  silk  sutures,  as  shown  in 
Figs.  106  and  107. 

Paraffin  Injection. — As  the  above  operation  leaves  a  lin- 
ear scar  on  the  anterior  nasal  line,  the  author  has  found 
it  much  better  to  correct  the  defect  by  building  up  the 
nasal  bridge,  or  the  entire  anterior  nasal  line  by  the 
subcutaneous  injection  of  one  of  the  paraffin  compounds, 
thus  overcoming  both  the  epicanthus  and  the  nasal  de- 
formity. In  fourteen  cases,  two  Japanese  and  the  rest 
negroes,  the  author  has  obtained  excellent  and  perma- 
nent results. 

The  process  herein  referred  to  was  first  suggested  in 
a  general  way  by  Gersuny,  and  has  been  extensively  and 


114      PLASTIC   AND    COSMETIC  .  SURGERY 

successfully  utilized  in  many  ways,  especially  in  this 
country.  A  special  chapter  is  given  to  the  method  else- 
where. 

Following  the  injection  of  the  substance  employed 
there  is  slight  swelling  for  a  few  days,  which  may  or  may 
not  involve  the  eyelids.  This  disappears  about  the  sec- 
ond or  third  day.  The  injected  material  becomes  organ- 
ized in  two  or  three  weeks'  time  and  gives  no  further 
trouble  to  the  patient. 

If  the  patient  complains  of  a  dull  pain  or  soreness 
in  the  area  thus  operated  upon,  the  application  of  cold 
extract  of  hamamelis  is  to  be  applied  on  little  squares 
of  sterilized  gauze,  which  usually  relieves  the  discom- 
fort in  a  few  hours. 

CANTHOPLASTY 

Canthoplasty  involves  the  lengthening  of  the  palpe- 
bral  fissure  at  the  external  canthus.  The  canthus  is  di- 
vided outward  to  the  extent  designed  with  a  pair  of 


FIQ.  108. — PROBE-POINTED  ANGULAR  SCISSORS. 

angular  scissors,  probe  pointed  (Fig.  108),  and  to  the 
extent  as  shown  in  Fig.  109. 

The  contiguous  ocular  conjunctiva  is  dissected  (Fig. 
110)  up  and  attached  to  the  newly  made  skin  margin  with 
silk  sutures  to  prevent  its  reunion,  one  suture  uniting  the 
angle  of  the  wound  with  the  raised  tip  of  conjunctiva 
(Fig.  111). 

The  sutures  are  allowed  to  remain  about  five  days. 


BLEPIIAROPLASTY 


115 


Traction  with  the  fingers  should  be  made  several  times 
each  day  to  thoroughly  separate  the  wound  and  to  pre- 
vent the  contraction  of  the  conjunctival  triangle,  which 
would  offset  entirely  the  object  of  the  operation.  As 
a  rule  the  fine  silk  sutures  heal  out  of  the  mucodermal 
margins  owing  to  the  softening  of  the  tissue  through  the 


FIG.  109. 


FIG.  110. 
EXTERNAL  CANTHOPLASTY. 


FIG.  111. 


increased  lachrymal  secretion  caused  by  the  irritation 
of  their  presence  and  the  resultant  reaction  following  the 
operation. 

A  slight  regional  conjunctivitis  usually  follows  this 
operation,  yielding  readily  to  simple  treatment,  often  re- 
quiring no  special  care  but  the  hygiene  of  secondary- 
wound  antisepsis. 

PTOSIS 

This  is  a  drooping  of  the  upper  eyelid,  due  to  con- 
genital or  paralytic  causes.  It  may  be  unilateral  or  bi- 
lateral. 

Apart  from  internal  and  proper  external  electrical 
and  other  treatment  the  simplest  surgical  method  to  be 
employed  is  to  remove  an  elliptical  piece  of  skin  from 
the  eyelid  and  to  suture  the  margins  of  the  wound 
together.  Care  should  be  taken  not  to  take  out  too 
much  tissue,  as  this  would  involve  inability  to  close 
the  lid. 


116      PLASTIC   AND    COSMETIC    SURGERY 

ANKYLOBLEPHARON 

A  condition  in  which  the  two  lid  margins  are  united 
by  cicatricial  adhesion.  These  should  be  removed  and 
the  margin  of  the  lids  be  rebuilt  by  any  of  the  methods 
suggested  if  possible.  Mucous-membrane  flaps  are  natu- 
rally to  be  preferred. 


WRINKLED   EYELIDS 

A  common  condition  after  middle  life,  when  not  due 
to  other  causes  than  normal  changes  in  the  skin  and  sub- 
cutaneous tissue.  Edematous  pressure  due  to  disease 
is  a  common  factor. 

The  wrinkling  may  be  marked  or  slight. 

To  correct  the  condition  is  to  remove  the  redundant 
or  baggy  tissue  by  excision,  as  massage  in  any  form 


FIQ.  112.  FIG.  113. 

BLEPHAROPLASTIES,  AUTHOR'S  METHOD. 

accomplishes  little  if  any  benefit.  The  shape  of  the  inci- 
sion should  be  made  to  include  the  loose  tissue  and  varied 
somewhat,  as  shown  in  Figs.  112  and  113. 

The  superior  line  of  incision  in  operations  of  the  lower 
lid  should  be  made  as  close  to  the  tarsal  line  as  is  prac- 
tical, so  as  to  show  as  little  of  the  resulting  scar  as  pos- 
sible. The  best  distance  is  about  an  eighth  of  an  inch 
below  the  tarsal  cartilage  fold.  Accuracy  in  making  the 


BLEPH  AROPL  AST  Y  1 17 

superior  line  of  the  incision  is  furthered  by  outlining  the 
flap  to  be  removed  with  a  very  fine  bistoury. 

In  operations  about  the  upper  lid  a  somewhat  wid- 
ened elliptical  piece  of  skin  is  excised  with  its  inferior 
margin  about  one  fourth  to  one  half  inch  above  the  tarsal 
line,  so  as  to  allow  the  line  of  union  to  lie  above  it  and 
within  the  curved  fold  when  the  eye  is  open. 

For  the  excision  it  will  be  found  best  to  use  a  fine 
pair  of  curved  eye  scissors,  beginning  the  incision  by 


FIG.  114. — CURVED  EYE  SCISSORS. 


raising  the  skin  at  the  outer  canthus  with  a  fixation  for- 
ceps or  tenaculum. 

Another  guide  to  outline  the  necessary  amount  of  tis- 
sue to  be  removed  is  to  mark  the  area,  prior  to  operation, 
with  India  ink  or  an  indelible  pencil.  The  parts  can  then 
be  snipped  away  readily  without  fear  of  causing  ectro- 
pion.  There  is  usually  very  little  bleeding,  and  in  most 
cases  the  tissue  is  exceedingly  thin. 

The  margins  of  the  wound  are  brought  together  with 
very  fine  twisted  silk,  using  the  continuous  suture  prefer- 
ably on  account  of  the  ease  with  which  it  can  be  removed. 

The  wound  is  then  powdered  with  a  suitable  antiseptic 
powder  and  covered  with  antiseptic  adhesive  silk  plaster 
moistened  with  an  antiseptic.  The  form  of  the  plaster 
should  be  of  suitable  shape,  not  too  wide,  and  nicked  so  as 
to  permit  of  proper  application. 

There  is  more  or  less  edema  following  the  operation, 
associated  with  or  without  discoloration,  which  disap- 
pears usually  without  treatment  in  forty-eight  hours.  It 
is  advisable  to  administer  a  saline  laxative  each  morn- 


118      PLASTIC    AND    COSMETIC    SUllGEliY 

ing  following  the  operation  for  several  days.  Small 
doses  of  magnesium  sulphate  answer  the  purpose  very 
well. 

The  sutures  are  withdrawn  in  from  twenty-four  to 
forty-eight  hours  after  having  been  carefully  softened 
with  warm  boric-acid  solution,  or  a  ten-per-cent  per- 
oxid-of -hydrogen  aqueous  solution.  The  early  removal 
of  the  sutures  prevents  stitch  cicatrices.  The  part  is 
again  powdered  as  before  and  covered  with  the  adhesive 
silk  plaster,  which  answers  both  purposes  of  protection 
and  splinting. 

The  resulting  cicatrization  is  so  surprisingly  little  as 
to  be  almost  invisible  in  the  great  majority  of  cases.  In 
patients  of  blond  complexion  the  redness  of  the  scar 
disappears  as  early  as  three  weeks,  but  is  more  prolonged 
in  persons  of  darker  type.  It  is  not  advisable  to  do 
both  upper  and  lower  eyelids  in  one  operation  to  avoid 
the  discomfort  of  the  edema  which  usually  follows. 

In  rare  instances  there  appears  a  hypertrophy  of  the 
scar  line,  which  is  best  treated  with  strips  of  thiosinamin 
plaster  mull,  twenty  per  cent,  applied  nightly  and  re- 
moved the  next  morning.  If  irritation  results  the  plas- 
ters should  be  discontinued  for  a  day  or  two. 

XANTHELASMA  PALPEBRARUM 

A  yellow  discoloration  of  irregular  patchlike  forma- 
tion in  the  skin  of  the  lids,  usually  about  the  region  of 
the  inner  canthus. 

The  condition  may  involve  both  upper  and  lower  lids 
symmetrically.  The  patches  are  generally  slightly  ele- 
vated and  vary  in  size.  They  make  their  appearance 
usually  late  in  life,  and  are  due  to  the  infiltration  of  the 
deeper  layers  of  the  skin  with  groups  of  cells  overbur- 
dened with  fat. 

They  are  best  removed  by  excision,  following  the 
method  of  the  preceding  operation.  There  may  or  may 


BLEPH  AROPL  AST  Y  1 19 

not  be  a  recurrence  of  the  disease  at  an  indefinite  period, 
when  the  tissue  must  again  be  removed. 


Remarks 

All  of  the  above  operations  in  blepharoplasty  can  be 
done  under  local  anesthesia,  using  either  the  two-  or 
three-per-cent  cocain  or,  preferably,  Beta-eucain  solu- 
tions. 

About  ten  minutes  after  each  operation  a  sharp  sting- 
ing sensation  is  experienced  in  the  eyelid  operated  upon, 
which  lasts  for  almost  an  hour  or  more,  and  indicates 
nothing  alarming  except  the  absorption  of  the  anesthetic 
and  a  return  to  the  normal  state.  A  sponge  dipped  into 
cold  sterile  water  relieves  the  parts  considerably  at  the 
time. 

It  is  advisable  to  inform  the  patients  of  this  symptom 
beforehand  to  avoid  unnecessary  alarm  on  their  part. 
Patients  are  easily  frightened  when  cutting  operations 
around  the  eye  are  undertaken,  and  should  be  apprised 
of  what  is  to  be  done,  and  what  to  expect,  especially  when 
the  operation  has  been  done  as  a  purely  cosmetic  one. 

After  the  sutures  are  removed  the  patient  is  in- 
structed to  allow  the  plasters  to  remain  until  they  fall 
off,  which  occurs  usually  in  about  two  days,  unless  there 
be  reasons  for  dressings  for  discharges  due  to  infection, 
the  result  of  carelessness  in  operating. 

Should  at  any  time,  from  carelessness  or  accident, 
the  wound  be  torn  open,  the  parts  need  only  be  brought 
together  with  adhesive  silk  plaster.  Healing  will  go  on, 
giving  practically  as  good  a  result  as  with  the  suture. 
Bardeleben  does  not  suture  these  wounds  at  all,  yet  the 
author  believes  it  a  safeguard  and  a  psychological  neces- 
sity in  most  cosmetic  cases. 


CHAPTER   X 

OTOPLASTY 
(Surgery  of  the  Ear} 

THIS  branch  of  surgery  has  to  do  with  the  corrective 
and  restorative  operations  of  and  about  the  external  ear. 

Traumatisms  of  the  auricle,  owing  to  the  exposed  posi- 
tion of  that  organ,  are  frequently  met  with  and  are 
commonly  the  result  of  stab  wounds,  direct  blows,  shot 
wounds,  and  human  bites,  especially  in  Spaniards  and 
Italians,  who  follow  this  queer  kind  of  revenge  upon  one 
another. 

Such  wounds  of  the  ear  may  involve  only  part  of  or 
the  whole  of  the  auricle.  Loss  of  auricular  substance 
may  also  be  the  results  of  gangrene  following  freezing 
or  the  direct  result  of  burns. 

Fracture  of  the  cartilage  of  the  ear  is  exceedingly 
rare  (Schwartze). 

Where  the  injury  is  one  of  incision  or  laceration 
without  loss  of  the  part,  the  site  should  be  cleansed  gently 
but  thoroughly  with  a  boric-acid  solution,  and  the  free 
torn  edges  brought  together  with  fine  silk  sutures.  If 
the  cartilage  projects  unduly  into  the  line  of  union  it 
should  be  trimmed  away  with  a  fine  pair  of  scissors 
(Roser).  Wounds  of  such  character  usually  heal  well, 
even  if  the  pieces  hang  loosely  by  threads  of  skin,  a  linear 
indent  of  cicatricial  tissue  usually  marking  the  traumatic 
separation  of  the  cartilage. 

In  the  negro  where  razor  cuts  about  the  ear  are  often 
seen,  a  hypertrophic  scar  or  keloid  is  liable  to  result, 

120 


OTOPLASTY  121 

even  to  the  extent  of  involving  the  punctures  of  the  sutur- 
ing needle. 

It  is  advisable  to  save  all  that  is  left  of  the  injured 
member,  even  if  entirely  severed,  with  the  hope  of  ob- 
taining union,  since  the  rebuilding  of  even  part  of  an 
ear  is  by  no  means  an  easy  matter,  owing  to  the  com- 
plicated formation  of  the  cartilaginous  frame. 

Wounds  about  the  meatus  are  liable  to  result  in  ste- 
nosis, which  should  be  guarded  against  by  packing  of 
small  strips  of  gauze  or  in  the  case  of  loss  of  substance 
immediately  about  the  orifice  by  the  employment  of  a 
sliding  flap  taken  from  the  skin  of  the  vicinity  or  by 
the  transplantation  of  a  nonpedunculated  skin  flap  taken 
from  some  other  part  of  the  body  and  sewn  into  place. 

RESTORATION   OF  THE  AURICLE 

If  a  loss  of  substance  of  the  auricle  cannot  be  avoided, 
the  surgeon  must  rely  upon  otoplastic  means  to  make 
up  the  deficiency. 

For  the  best  cosmetic  defects  it  is  desirable  to  have 
as  much  of  the  cartilage  remaining  as  possible.  The 
stump  of  the  ear  is  freshened  at  its  outer  margin  with 
the  bistoury  and  the  frontal  skin  carefully  dissected  away 
from  the  cartilage  to  the  extent  of  a  quarter  inch. 

A  flap,  one  third  larger  than  the  defect  to  be  supplied, 
is  now  outlined  on  the  skin  back  of  the  ear  in  such  a 
way  that  the  flap  included  therein  will  not  be  subjected 
to  too  much  torsion. 

This  flap  must  necessarily  vary  in  shape  and  size,  ac- 
cording to  the  nature  of  the  deformity  to  be  corrected. 
It  may  even  extend  into  the  hair  of  the  scalp  over  the 
squamoparietal  region  of  the  head  or  a  part  of  the  neck 
laterally  and  below  the  ear. 

This  flap,  after  careful  estimation  as  to  size,  should 
be  dissected  up  freely  down  to  the  periosteum,  leaving 
a  bridge  of  tissue  at  the  point  where  the  least  resistance 


122      PLASTIC    AND    COSMETIC    SURGERY 

will  be  caused  after  its  free  end  has  been  sutured  to  the 
remains  of  the  ear. 

The  free  flap  is  stitched  to  the  stump  with  several  silk 
sutures.  After  bleeding  has  been  controlled,  a  few  lay- 
ers of  borated  gauze  are  introduced  under  the  flap  to 
prevent  its  reattachment  and  to  encourage  its  thicken- 
ing, and  the  entire  site  of  the  operation  dusted  over  with 
an  antiseptic  powder,  and  covered  with  loose  folds  of 
sterile  gauze.  A  bandage  can  be  lightly  applied  over  the 
whole  to  keep  the  parts  in  place. 

The  success  of  union  of  the  flap  depends  upon  the 
immobility  of  the  parts  while  healing  is  taking  place. 
The  patient  is  to  rest  at  night  in  a  semirecumbent  posi- 
tion with  the  head  held  down  firmly  on  the  uninjured  side 
with  the  aid  of  a  tight-fitting  linen  cap  made  for  the  pur- 
pose and  tied  by  attached  tails  of  the  same  material  to 
the  bed  in  such  a  way  that  the  head  cannot  be  turned 
during  sleep,  yet  allowing  of  more  or  less  movement  in 
either  direction,  never  enough,  however,  to  cause  ten- 
sion in  the  flap.  During  the  day  the  patient  should  be  on 
his  feet  as  usual,  since  the  operation  is  hardly  severe 
enough  to  compel  absolute  rest. 

As  soon  as  the  union  of  the  flap  to  the  ear  has  been 
established,  which  is  about  the  eighth  day,  the  sutures 
are  carefully  removed  to  avoid  irritation,  but  the  pedicle 
of  the  flap  is  not  to  be  severed  until  the  tenth  or  fifteenth 
day,  when  satisfactory  circulation  has  been  established. 

The  flap  when  severed  will  shrink  more  or  less,  but 
will  be  seen  to  be  somewhat  thicker  than  when  dissected 
up  in  the  primary  operation. 

Nothing  should  be  done  for  a  few  days  hereafter  ex- 
cept to  keep  the  granulating  surfaces  of  the  flap  and 
back  of  the  ear  aseptically  clean  and  healthy. 

As  soon  as  the  flap  loses  its  pale  color  and  takes  on 
a  pinkish  glow  it  may  be  deemed  safe  to  cover  the  granu- 
lating or  secondary  wound  on  the  head  with  grafts  of 
skin,  using  whatever  method  most  suitable  for  the  pur- 


OTOPLASTY  123 

pose.  The  transplantation  of  a  single  flap  of  skin  taken 
from  the  anterior  border  of  the  arm  is  perhaps  productive 
of  the  best  result. 

To  assure  of  success  the  graft  may  be  healed  under 
the  blood  dressing ;  the  methods  for  which  have  been  fully 
described  heretofore. 

Once  the  secondary  wound  is  healed  the  surgeon's 
attention  must  be  given  to  the  flap  attached  to  the  stump. 
By  the  aid  of  the  judicious  use  of  the  nitrate-of -silver 
pencil  certain  parts  of  this  flap  may  be  stimulated  to 
become  thickened. 

The  upper  or  outer  border  of  the  flap  should  be  taken 
under  operation  first  to  form  the  new  helix  of  the  ear. 
This  can  be  done  by  making  several  incisions  along  its 
free  edge  and  gently  turning  backward  these  small  flaps 
so  that  their  raw  surfaces  face  that  of  the  flap. 

This  procedure,  if  neatly  done,  will  eventually  give  a 
thickened  border  to  the  superior  rim. 

Should  the  flap  have  been  cut  large  enough  to  permit 
of  lining  its  entire  back  this  can  be  done,  but  care  must 
be  exercised  not  to  cause  a  too  abrupt  folding  over  of  the 
same,  as  gangrene  is  likely  to  result.  The  more  slowly 
this  freshening  is  accomplished  the  better  will  the  result 
be  eventually. 

If,  however,  this  flap  will  not  permit  of  autolining, 
and  its  raw  surface  presents  a  healthy  granulated  ap- 
pearance, recourse  may  be  had  to  the  transplantation  of 
a  flap  from  the  arm  upon  it  and  fastened  to  the  denuded 
edges  of  the  aural  flap. 

As  soon  as  healing  has  been  established  a  number  of 
delicate,  often  complicated  incisions  are  made  in  the 
newly  formed  part  of  the  ear  to  give  it  proper  shape  and 
size. 

Kuhnt  has  obtained  excellent  results  in  a  case  where 
he  employed  a  flap  from  the  back  of  the  ear,  combined 
with  two  pedunculated  tongue-shaped  flaps  taken  from 
the  cheek  above  and  the  neck  below,  which  he  twisted 


124      PLASTIC    AND    COSMETIC    SURGF^RY 


about  back  of  the  flap  of  the  newly  formed  ear,  so  that 
their  epidermal  surfaces  faced  its  raw  surface  with  the 
object  of  giving  greater  thickness  to  the  ear  at  that 
point. 

At  best,  however,  the  restoration  of  an  entire  ear 
may  be  considered  impracticable,  and  only  in  such  cases 
where  the  greater  part  of  the  ear  remains  can  cosmetic 
results  be  looked  for. 

In  the  illustration  shown  the  author  restored  the 
upper  third  of  the  ear  shown  above  the  line  drawn  ob- 
liquely across  the  ear.  Seventeen  delicate  operations 

were  necessary  to  obtain 
the  result  (see  Fig.  115). 
Where  the  loss  of 
substance  is  not  too 
great  and  along  the  he- 
lix of  the  ear,  a  flap  can 
be  taken  from  the  back 
of  the  ear,  leaving  it  at- 
tached at  its  cicatrized 
union  with  the  primary 
wround,  and  sliding  this 
flap  upward  or  outward 
until  the  defect  of  the 
helix  is  overcorrected  to 
allow  for  contraction  and 
suturing  the  flap  in  its 
new  position. 

The  secondary  wound  if  too  large  to  permit  of  direct 
union  with  sutures  may  at  once  be  covered  with  a  flap 
taken  from  the  anterior  border  of  the  arm,  or,  if  pre- 
ferred, from  the  inner  aspect  of  the  calf  of  the  leg.  The 
wound  occasioned  by  the  removal  of  the  graft  can  easily 
be  closed  by  suture,  leaving  simply  a  linear  scar  of  lit: 
tie  consequence.  Usually  such  defects  of  the  rim  can 
be  hidden  by  the  combing  of  the  hair,  especially  in 
women. 


FIG.  115. — PARTIAL  RESTORATION  OF  THE 
AURICLE.    (Author's  case.) 


OTOPLASTY  125 

AURICULAR  PROTHESES 

When  the  injury  has  resulted  in  complete  loss  of  the 
organ  or  so  much  of  it  that  its  remaining  stump  will  not 
permit  of  otoplasty,  protheses  or  artificial  ears  or  parts 
of  ears  may  be  employed  to  render  the  patient  less  un- 
sightly. These  protheses  are  usually  made  of  aluminum, 
papier  mache,  or  rubber,  and  painted  to  match  the  good 
ear.  They  are  attached  with  a  special  kind  of  gum, 
termed  zinc-leim,  which  makers  of  such  protheses  furnish, 
or  are  held  by  metal  springs,  which  are  inserted  under 
strips  or  bridges  of  skin  surgically  created  for  the  pur- 
pose. The  esthetic  effect  is  surprisingly  good  in  most 
cases. 

COLOBOMA 

A  very  common  injury  observed  in  women  is  lacera- 
tion of  the  lobule  of  the  ear  or  ears,  generally  due  to  the 
wearing  of  heavy  earrings,  which  gradually  cut  their  way 
through  the  tissues.  Coloboma  may  be  occasioned  by  the 
forcible  tearing  out  of  the  earrings;  it  has  also  been 
found  to  be  congenital  in  rare  cases. 

The  simplest  method  for  correcting  this  deformity  is 
to  cut  away  both  cicatrized  edges  of  the  defect  by  the 
aid  of  the  angular  scissors,  exposing  fully  the  width  of  the 
lobular  tissue  on  both  sides  (Fig.  116),  as  the  cicatricial 
edges  are  likely  to  be  thinner  than  the  lobule  proper,  and 
if  brought  together  would  leave  a  depression  along  the 
line  of  union.  The  freshened  cut  surfaces  are  brought 
together  with  fine  silk  sutures,  an  inferior  one  being  taken 
in  the  outer  border,  so  as  to  establish  perfect  coaptation 
at  this  point  (Fig.  117). 

The  objection  to  the  above  operation  is  that  invariably 
owing  to  the  resultant  contraction  a  notch  is  formed  at 
the  union  of  the  angles  of  the  freshened  wound.  To 
avoid  this  the  operation  shown  in  Fig.  118  is  to  be  em- 
ployed (Greene). 


126      PLASTIC    AND    COSMETIC    SURGERY 


The  bistoury  is  thrust  through  the  lobule  at  the  point 
A  and  an  incision  is  made  to  follow  at  a  little  distance 


FIG.  116. — CORRECTION  OF  LOBULAR 
DEFECT. 


FlG.   117. COAPTATION   OF   WOUND. 


the  defect  along  the  line  D.    This  frees  the  cicatrix  except 
at  the  pedicle  A.     A  transverse  incision  is  now  made 


FIG.  119. 


GREENE  METHOD. 


above  the  point  A  corresponding  to  the  curved  exsection 
of  the  opposite  side  except  for  a  thin  strip  of  tissue  B. 


OTOPLASTY  127 

Tli is  delicate  little  flap  is  preserved  and  severed  a  short 
distance  beyond. 

The  raw  edges  when  now  brought  in  apposition  will 
assume  the  form  in  Fig.  119.  The  wound  is  sutured  as 
in  the  simpler  operation. 

These  operations  are  best  performed  under  local  an- 
esthesia, the  two-per-cent  eucain  being  preferred.  There 


FIG.  120. — NOYES'S  CLAMP. 


is  practically  little  bleeding,  but  even  this  may  be  avoided 
by  applying  a  large  Noyes'  compression  clamp  with  its 
angular  arms  so  placed  as  to  include  the  entire  lobule 
(Pig.  120). 


MALFORMATION   OF  THE  LOBULE 

There  may  be  an  enlargement  of  or  an  absence  of  the 
lobule. 

ENLARGEMENT  OF  THE  LOBULE 

In  the  enlargement  of  the  lobule  the  operation  last  de- 
scribed may  be  resorted  to,  making  the  now  supposed 
coloboma  the  triangular  amount  of  tissue  to  be  removed. 
It  will  be  found  that  the  upper  curve  of  the  incisions 
must  be  carried  much  higher  in  cases  of  this  kind,  fur- 
thermore, that  they  should  define  a  sharper  angle  at  this 
point. 

The  simple  exsection  of  a  triangular  piece  of  the 
lobule  and  suturing  is  commonly  practiced,  with  the  ob- 
jection of  the  notch  previously  referred  to.  This  opera- 
tion is  very  quickly  done,  and  if  care  be  taken  in  bringing 
the  raw  surfaces  together  neatly  a  splendid  result  is 


attained,  especially  if  the  incisions  are  made  obliquely  to 
the  plane  of  the  skin. 

ATTACHMENT  OF  THE  LOBE 

There  may  be  a  shortening  of  the  lobule,  or,  as  is 
more  frequently  seen,  the  attachment  of  the  inner  lat- 
eral border  of  the  lobe  to  the  skin  opposite. 

This  attachment  of  the  lobe  has  been  alleged  by  crim- 
inologists  to  be  a  mark  of  the  degenerate.  If  this  be 
so  it  can  scarcely  apply  to  the  Japanese,  in  whom  it  is 
found  as  a  racial  fact. 

As  the  defect  is  often  objected  to  by  patients  its  cor- 
rection may  be  considered  briefly. 

An  incision  is  made  in  the  inferior  auricle  and  in  the 
skin  below  it,  as  shown  by  the  dotted  lines  in  Fig.  121, 
removing  the  triangular  piece  of  tissue  included  therein. 


FIG.  121.  FIG.  122. 

CORRECTION  OF  ATTACHED  LOBE. 

The  wound  is  then  sutured  with  fine  silk,  as  shown  in 
Fig.  122,  and  allowed  to  heal.  The  result  is  very  grati- 
fying in  most  cases. 


MALFORMATION   OF  THE  AURICLE 

Malformations  of  the  ear  are  due  to  the  arrest  of  de- 
velopment, termed  microtia,  excessive  development,  or 
macrotia,  and  malposition. 


OTOPLASTY 


129 


MlCROTIA 

The  total  absence  of  the  auricular  appendage  is  quite 
rare.  One  or  the  other  part  of  the  ear  is  usually  found, 
either  partially  or  fully  developed,  giving  to  the  ear  an 
irregular  rolled-up  appearance.  This  defect  may  be  uni- 
lateral or  bilateral. 

It  may  be  associated  with  congenital  fistula  (Fistula 
auris  congenita),  varying  in  length  from  one  fourth 
to  one  inch,  and  secreting  a  serouslike  fluid.  These  fis- 
tulas are  usually  found  anteriorly  and  above  the  tragus, 
the  lobule,  or  more  rarely  at  the 
crus  helix,  or  even  behind  the 
ear.  Sometimes  these  fistulae 
communicate  with  the  middle 
ear  or  even  the  esophagus. 
They  are  due  to  imperfect  de- 
velopment in  utero.  In  microtia 
little  can  be  done  surgically, 
since  the  malformation  is  usu- 
ally so  pronounced  as  to  ex- 
clude all  methods  of  restora- 
tion. 

Szymanowski  advises  mak- 
ing an  ear  from  the  skin  imme- 
diately back  of  the  auditory 
canal  if  present,  making  the  in- 
cisions of  the  shape  shown  in 
Fig.  123. 

The  flap  included  in  these  incisions  is  dissected  up  and 
doubled  on  itself  posteriorly.  The  doubled  flap  thus 
formed  is  brought  forward  and  placed  as  near  into  the 
linear  position  as  the  ear  should  have.  The  flap  is  then 
sutured  through  and  through  to  make  the  raw  surfaces 
heal  together.  The  secondary  wound  and  the  treatment 
of  the  flap  are  carried  out  as  already  referred  to  under 

restoration  of  the  auricle. 
10 


FIG.  123. — RESTORATION  OF  AU- 
RICLE, SZYMANOWSKI  METHOD. 


130     PLASTIC   AND    COSMETIC    SURGERY 

Several  later  delicate  operations  are  done  to  add  to 
the  shape  of  the  newly  made  organ,  but  at  best  the  effect 
is  far  from  even  good. 

In  the  case  of  Mr.  B.,  illustrated  in  Fig.  124,  an  at- 
tempt was  made  to  enlarge  the  somewhat  elastic  roll  of 
tissue  corresponding  to  the  helix  by  several  injections 
of  paraffin.  The  result  proved  to  be  anything  but  satis- 
factory ;  in  fact,  the  prominence  of  the  malformed  upper 
ear  was  made  more  evident,  and  painful  when  subjected 
to  pressure,  so  that  the  patient  was  compelled  to  refrain 
from  lying  on  that  side  of  the  head. 

There  had  been  also  congenital  atresia  of  the  auditory 
meatus,  which  had  been  operated  for,  leaving  a  hair- 


Fia.  124. — AURICULAR  STUMP  FOR  ATTACH- 
MENT OF  ARTIFICIAL  EAR. 


FIQ. 


125.  —  AURICULAR 

THESIS. 


PRO- 


lined  opening,  leading  down  to  a  useless  middle  ear,  a 
condition  sometimes  associated  with  microtia. 

In  presenting  himself  to  the  author  for  operation  it 
was  decided  that  the  otoplastic  methods  for  the  restora- 


OTOPLASTY 


131 


tion  of  the  ear  were  out 
of  the  question,  as  is  usu- 
ally the  fact  in  these 
cases. 

The  hard  mass  of  tis- 
sue referred  to  and  cor- 
responding- to  the  helix 
was  reduced  consider- 
ably, so  that  the  stump 
obtained  was  soft  and 
pliable,  with  not  only  the 
object  of  overcoming  the 
sensitiveness  and  incon- 
venience of  the  part,  but 
to  obtain  as  good  a  base 
for  the  attachment  of  an 
artificial  ear  as  possible 
(see  Fig.  124). 

The  author  advises  a  complete  amputation  of  such 
underdeveloped  ears,  since  a  better  and  firmer  seat  of 


FIG.    126. —  AURICULAR    PROTHESIS   AP- 
PLIED TO  STUMP. 


FIG.    127. — ANTERIOR   VIEW   OF  AU- 
RICULAR PHOTHESIS. 


FIG.   128. — POSTERIOR  VIEW   OF  AU- 
RICULAR PHOTHESIS. 


attachment  is  offered  thereby  to  the  prothesis  to  be  worn 
over  it,  at  the  same  time  giving  the  artificial  organ  a 
better  position  in  reference  to  its  normal  relation  to  the 
face.  An  irregular  stump  makes  this  more  or  less  diffi- 
cult, as  in  the  case  just  referred  to,  but  even  these  pa- 
tients are  loath  to  part  with  an  irregular  ugly  mass  of 
tissue  they  consider  themselves  thankful  to  be  born  with. 

The  auricular  prothesis  used  in  this  case  is  shown  in 
Fig.  125,  and  its  position  and  appearance  when  placed 
on  the  stump  is  shown  in  Fig.  126. 

Another,  showing  both  anterior  and  posterior  sur- 
faces, is  given  in  Figs.  127  and  128. 

The  fistular  conditions  mentioned  should  be  thor- 
oughly dissected  out  and  healed  from  the  bottom  when 
practical  by  antiseptic  gauze  packing.  Those  involving 
the  middle  ear  require  special  treatment  that  cannot  be 
included  under  plastic  procedure. 

MACKOTIA 

Abnormal  enlargement  of  the  ear  is  often  found  in  the 
idiot,  but  is  commonly  seen  as  a  hereditary  defect  in  many 
without  having  the  least  relation  to  the  mental  develop- 
ment of  the  person.  These  conditions  occur  more  fre- 
quently in  men  than  in  women. 

Enlargement  always  depends  upon  overdevelopment 
of  the  cartilaginous  structure  of  the  auricle,  and  may 
also  be  the  result  of  direct  violence,  the  result  of  blows 
upon  the  organ,  as  in  prize  fighters,  football  players,  and 
other  athletes. 

Following  violence  the  auricle  undergoes  either  an 
acute  or  chronic  hypertrophy  of  the  chondrium,  resulting 
in  the  condition  known  as  the  "  cauliflower  ear." 

Again,  there  may  be  hematoma  occasioned  by  direct 
violence,  termed  othematoma  traumaticum,  or  a  spon- 
taneous development  of  such  hematoma  without  any 
appreciable  injury,  as  found  in  the  insane.  In  the  latter 
form  the  disease  appears  suddenly  without  warning  or 


OTOPLASTY  133 

inflammatory  manifestations,  the  hematoma  reaching  its 
full  size  in  three  or  four  days,  after  which  a  passive  reso- 
lution in  the  form  of  absorption  of  the  tumor  takes  place 
associated  more  or  less  with  an  organization  of  the  blood 
mass,  and  leaving  the  auricular  appendage  unduly  en- 
larged, distorted,  and  thickened,  with  here  and  there 
islands  of  seemingly  detached  or  displaced  cartilage 
firmly  adherent  to  the  overlying  skin. 

Early  in  these  cases  much  can  be  done  by  the  appli- 
cation of  external  medication,  depletion,  and  pressure 
bandage,  and  the  removal  of  the  effusion  producing  the 
swelling  and  lying  between  the  perichondrium  and  the 
cartilage,  by  the  introduction  of  a  trocar  cannula  or  by 
incision,  as  may  be  required. 

The  union  between  cartilage  and  perichondrium  is 
always  slow,  requiring  about  three  weeks  in  the  traumatic 
variety  and  often  months  in  the  noninflammatory  form. 

Be  the  enlargement  due  to  whatever  cause,  the  patient 
not  infrequently  presents  himself  for  a  correction  of  the 
deformity. 

The  slightest  of  such  deformities  is  a  tiplike  enlarge- 
ment of  the  outer  and  upper  angle  of  the  helix,  most  com- 
monly unilateral.  This  has  been  termed  "  fox  ear." 

In  this  condition  there  is  more  or  less  loss  of  the  curl 
of  the  helix,  with  flattening  beginning  well  down  in  the 
fossa,  extending  upward,  and  terminating  in  a  triangular 
cartilaginous  tip  resembling  the  ear  of  an  animal,  hence 
the  name. 

The  correction  of  this  fault  is  quite  simple.  An  in- 
cision somewhat  larger  than  the  base  of  the  cartilaginous 
triangle  is  made  under  a  local  anesthetic  about  one  fourth 
inch  below  and  back  of  the  line  corresponding  to  the 
superior  border  of  the  helix.  The  cartilage  is  exposed 
through  this  incision  and  excised  with  a  fine  curved  scis- 
sors without  wounding  the  anterior  skin  of  the  helix, 
and  the  incision  neatly  sutured,  leaving  the  now  redun- 
dant skin  to  contract. 


134     PLASTIC   AND    COSMETIC    SUBGERY 

In  this  manner  the  fault  is  corrected  without  any 
appreciable  scar. 

The  sutures  can  be  removed  in  three  or  four  days. 

In  the  correction  of  niacrotia  various  surgical  meth- 
ods may  be  employed,  yet  none  can  be  emphasized,  as 
exclusively  indicated,  inasmuch  as  the  enlargements  may 
involve  one  or  the  other  part  of  the  pinna. 

The  greatest  fault  with  most  of  these  ears  lies  in  the 
overdevelopment  of  the  triangular  antihelix  or  that  area 
lying  posterior  to  the  fossa  of  the  antihelix  and  the  fossa 
of  the  helix,  although  in  many  cases  the  greatest  mal- 
formation is  found  in  the  concha  itself. 

The  following  methods  for  operation  are  therefore 
given  not  so  much  for  their  individual  merit,  but  to  act 
as  a  guide  in  the  selection  of  an  appropriate  election  or 
modification  for  specific  cases. 

Schwartze  Method. — Schwartze  advises  and  has  obtained 
excellent  results  by  removing  a  long  elliptical  piece  of 


FIG.  129 


FIG.  130. 
SCHWARTZE  METHOD. 


FIG.  131. 


the  entire  thickness  of  the  pinna,  including  both  skin  and 
cartilage,  from  the  fossa  of  the  helix,  followed  by  the 
excision  of  a  triangular  section  with  its  base  correspond- 
ing to  the  outer  border  of  the  helix  and  its  apex  terminat- 
ing well  in  the  concavity  of  the  concha.  The  scheme  of 


OTOPLASTY 


135 


procedure  is  shown  in  Figs.  129  and  130.  The  raw  edges 
are  brought  together  by  fine  silk  sutures,  which  are  made 
to  pass  directly  through  the  cartilage,  and  tied  carefully 
to  prevent  any  change  of  the  transfixed  parts,  which 
would  mar  the  result  of  the  operation  more  or  less  and 
necessitate  further  interference.  The  arrangement  of  the 
sutures  and  the  disposition  of  the  parts  are  shown  in 
Fig.  131. 

Parkhill  Method. — Parkhill  advises  a  semilunar  incision 
from  the  fossa  of  the  helix  with  a  rhomboidal  exsection 


FIG.  132.  FIQ.  133. 

PARKHILL  METHOD. 

of  the  helix,  as  shown  in  Fig.  132,  and  suturing  the  parts, 
as  shown  in  Fig.  133. 

The  tonguelike  ends  of  the  semilunar  incisions  must, 
of  course,  vary  in  length,  according  to  the  amount  of  tis- 
sue necessary  to  remove  to  facilitate  accurate  juxtaposi- 
tion of  the  newly  designed  flaps. 

Author's  Method. — The  latter  operation  is  most  success- 
ful where  the  upper  part  of  the  pinna  is  unusually  flat. 
It  does  not  correct  this  flatness,  however,  which  is  often 
an  objection,  hence  the  author  suggests  excising  a  sec- 
tion of  the  entire  thickness  of  the  ear  from  the  fossa 


136     PLASTIC   AND    COSMETIC    SUEGEEY 

somewhat  in  the  form  shown  in  Fig.  134,  curving  the  two 
deeper  invading  incisions,  so  that  when  the  parts  are 
brought  together  a  concavity  will  be  given  the  antihelix, 
as  in  the  natural  auricle. 

The  rearrangement  of  the  parts  in  this  event  is  shown 
in  Fig.  135.  The  only  objection  to  the  above  may  be  found 
in  the  two  linear  scars  across  the  antihelix  entirely  over- 
come by  the  Parkhill  operation,  wherein  the  line  of  union 
falls  just  below  the  rim  of  the  helix  and  into  the  groove 
commonly  found  there,  yet  any  of  these  scars  shows  little 


FIG.  134. 


FIQ.  135. 


AUTHOR'S  METHOD. 


in  well-done  operations  and  when  union  takes  place  by 
first  intention. 

There  will  always  appear  a  notchlike  depression 
where  the  newly  cut  ends  of  the  helix  are  brought  to- 
gether, owing  to  the  cicatrix  involving  the  space  between 
the  cartilaginous  borders. 

Inasmuch  as  this  notch  necessarily  shows  the  most 
prominent  part  of  the  ear,  the  author  advocates  the  fol- 
lowing method  in  which  the  notch  is  brought  anterior  to 
the  fossa  of  the  antihelix;  in  other  words,  near  to  the 
point  of  the  union  of  the  helix  with  the  skin  of  the  face 
about  on  a  line  with  the  superior  border  of  the  zygomatic 
process ;  a  point  where  the  hair  is  in  close  proximity  with 
the  ear  and  where  the  scar  can  be  more  easily  covered. 


137 


The  form  of  incision  is  somewhat  sickle  shaped,  the 
upper  curvature  of  the  incision  following  the  inferior 
border  of  the  helix  and  extending  well  into  the  fossa  of 
the  helix,  as  shown  in  Fig.  136.  Where  the  antihelix  is 


FIG.  136.  FIG.  137. 

AUTHOR'S  METHOD. 

particularly  large  a  triangular  section  may  be  removed, 
as  shown  at  A,  with  a  corresponding  shortening  of  the 
helix  flap  at  B.  The  latter  gives  more  contour  to  the  ear 
as  well. 

The  parts  are  brought  together  and  sewn  into  posi- 
tion, as  shown  in  Fig.  137. 

AURICULAR  APPENDAGES 

Small  nipplelike  projections  of  skin  or  elongated  tume- 
factions of  connective  tissue  are  sometimes  found  about 
the  tragus,  the  lobule,  or  on  the  neck.  They  are  easily 
removed  by  encompassing  their  bases  with  an  elliptical 
incision  and  amputating  them  a  little  below  the  level  of 
the  skin  and  suturing  the  wound  in  linear  form. 

POLYOTIA 

Auricular  appendages  may  contain  small  pieces  of 
cartilage  or  resemble  crudely  the  auricle  in  miniature. 


138      PLASTIC    AND    COSMETIC    SURGERY 

This  condition  is  termed  polyotia.  One  or  more  of  these 
supernumerary  ears  may  be  found  anterior  or  posterior 
to  the  true  ear  or  even  below  it  on  the  skin  of  the  neck. 

In  the  case  reported  by  Wilde  there  were  four  ears, 
the  two  abnormal  ones  being  situated  on  the  neck  at  either 
side.  Langer  has  reported  a  similar  case.  The  condi- 
tion may  be  unilateral  or  bilateral. 

This  congenital  malformation  is  corrected  by  simple 
amputation,  as  described  under  minor  auricular  append- 
ages. 

MALPOSITION   OF   THE  AURICLE 

The  most  common  deformity  met  with  in  ears  is  undue 
prominence.  The  ears  stand  out  from  the  head  at  an  ob- 
tuse angle,  often  lopping  forward  and  downward,  giving 
the  patient  a  stupid  appearance.  This  condition  is  usu- 
ally inherited,  but  may  be  acquired  during  childhood  by 
the  careless  wearing  of  caps  that  crowd  the  pinnae  for- 
ward and  away  from  the  head.  The  habit  of  ear-pulling 
is  also  said  to  be  a  cause,  also  the  faulty  position  of  the 
head  during  sleep.  The  deformity  is  usually  bilateral, 
but  in  the  majority  of  cases  one  ear  usually  projects 
more  than  the  other. 

Where  the  deformity  is  recognized  during  infancy  the 
ears  should  be  simply  bandaged  to  the  head  with  a  suit- 
able bandage  or  ear  cap,  procurable  for  that  purpose  with 
the  hope  that  the  cartilages  may  thus  be  influenced  dur- 
ing their  period  of  hardening  and  growth. 

Invariably  these  patients  are  seen  too  late,  and  oper- 
ative procedures  alone  will  restore  the  ears  to  their  nor- 
mal position. 

The  earlier  in  life  such  an  operation  is  performed 
the  more  satisfactory  is  the  result,  inasmuch  as  the  carti- 
lage of  the  ear  is  more  pliable,  and  hence  more  suscep- 
tible of  readjustment;  moreover,  the  operation  when 
done  early  in  life  necessitates  only  the  removal  of  an 
elliptical  piece  of  skin  from  the  back  of  the  ear,  accord- 


OTOPLASTY 


139 


FIG.  138. — MONKS'  METHOD. 


ing  to  Monks,  and  suturing  of  the  wound,  as  shown  in 
Fig.  138. 

The  elliptical  form  of  the  incision  must,  however,  be 
changed  according  to  the  varied 
prominence  of  various  parts  of 
the  ear.  When  the  ear  lops  for- 
ward, it  should  be  broader  above 
and  narrower  below,  and  vice 
versa  in  the  event  when  the 
concha  is  overprominent. 

When  the  patient  is  less  than 
fourteen  or  fifteen  years  of  age 
a  general  anesthetic  should  be 
employed,  but  in  older  patients 
the  operation  can  be  easily  un- 
dertaken under  local  use  of  two- 
per-cent  eucain  solution. 

Author's  Method. — The  method  followed  by  the  author  is 
to  thoroughly  anesthetize  the  back  of  the  ear,  the  pa- 
tient lying  in  a  recumbent  position  with  the  head  to  one 
side,  sufficient  to  place  the  ear  to  be  operated  upon  in  as 
convenient  position  for  operation  as  is  possible.  A  rub- 
ber cap  is  drawn  over  the  head  to  cover  the  hair. 

An  incision  is  now  made  along  the  whole  of  the  back 
of  the  ear  as  far  down  as  the  sulcus,  where  the  retro- 
aural  integument  joins  that  of  the  neck. 

The  incision  should  involve  the  skin  only,  and  vary 
from  three  fourths  to  one  half  an  inch  from  the  outer 
border. 

At  once  the  blood  will  ooze  from  the  line  of  incision. 
The  operator  now  presses  the  ear  backward  on  the  bare 
skin  of  the  head,  leaving  an  imprint  of  the  bleeding  line 
on  the  skin  there. 

A  second  incision  is  made  along  this  line,  giving  the 
total  outlining  incision  a  heart-shaped  form,  as  shown 
in  Fig.  139. 

The  skin  within  this  area  is  now  dissected  up  quickly. 


140     PLASTIC   AND    COSMETIC    SURGERY 

There  will  be  more  or  less  bleeding  from  the  post- 
auricular  vessels,  which  can  easily  be  controlled  by 
sponge  pressure,  or  with  one  or  two  artery  forceps  of 
the  mosquito-bill  pattern.  The  wound  should  be  large 
enough  to  overcorrect  the  fault,  as  the  ear  springs  out 
more  or  less  when  healed. 

Sutures  are  now  introduced.  When  necessary  one  or 
two  catgut  sutures  are  taken  through  the  concha,  not 
going  through  the  anterior  skin,  however,  and  the  deeper 
tissue  back  of  the  ear  and  tied.  These  hold  the  cartilage 
in  place. 


FIG.  139. — AUTHOR'S  METHOD. 


FIG.  140 — CARTILAGE  TO  BE  REMOVED. 
(Author's  method.) 


For  the  coaptation  of  the  skin  the  continuous  suture 
is  to  be  preferred,  but  when  the  cartilage  suture  is  em- 
ployed it  will  be  found  impracticable,  owing  to  the  close 
position  of  the  ear  to  the  head.  In  that  event  interrupted 
sutures  must  be  placed,  as  shown  in  the  Monks  opera- 
tion, and  tied  after  the  cartilage  has  been  fixed  as  de- 
scribed. 


OTOPLASTY  141 

Where  it  is  deemed  necessary  to  fix  the  cartilage  in 
this  way,  the  author  advises  to  remove  an  elongated  ellip- 
tical piece  of  the  concha,  as  shown  in  Fig.  140. 

This  is  neatly  done  by  outlining  the  section  with  the 
scalpel,  and  excising  it  with  the  aid  of  a  fine  pair  of  scis- 
sors, half  rounded ;  the  operator  holding  the  index  finger 
of  the  left  hand  in  the  depression  of  the  concha  anteriorly 
as  a  guide  to  avoid  injuring  the  skin. 

After  the  elliptical  exsection  a  linear  incision  with  the 
scissors  may  be  made  both  superiorly  and  inferiorly  to 
further  mobilize  the  springy  shell  of  the  ear,  which  will 
then  be  found  to  fall  easily  into  place. 

The  bleeding  in  the  latter  method  is  more  severe, 
since  the  posterior  auricular  arteries  and  the  auricular 
branch  of  the  occipital  have  to  be  severed,  yet  ligation 
is  rarely  necessary. 

The  interrupted  suture  may  now  be  applied,  varying 
the  site  of  puncture  as  below  or  above  its  fellow  puncture, 
as  made  necessary  by  the  droop  of  the  ear,  with  the  object 
of  shifting  it  into  a  normal  position ;  or  in  other  words,  by 
raising  or  lowering  it  upon  tightening  the  sutures. 

The  continuous  suture  is  to  be  preferred,  however, 
when  the  cartilage  has  been  removed  as  described,  since 
the  ear  has  now  become  quite  mobile  and  is  easily  placed 
in  position. 

When  the  removal  of  these  sutures,  which  should  be 
of  Nos.  5  or  6  twisted  silk,  is  considered,  one  can  compre- 
hend the  advisability  of  this  form  of  wound  closure. 

The  ear  will  now  appear  to  lie  quite  close  to  the  head, 
compared  with  the  original  position,  as  shown  in  Figs. 
141  and  142. 

The  patient  is  now  turned  so  as  to  present  the  other 
ear,  a  pad  of  gauze  and  absorbent  cotton  being  placed 
under  the  ear  operated  on  for  comfort's  sake. 

The  second  ear  is  operated  as  was  the  first,  the  oper- 
ator having  taken  note  of  the  form  and  size  of  the  inci- 
sion of  the  ear  just  finished. 


142      PLASTIC   AND    COSMETIC    SURGERY 


Both  ears  sutured,  the  wounds  are  cleansed  thor- 
oughly, though  gently,  with  fifty-per-cent  peroxid  of  hy- 
drogen and  dried  and  dusted  over  with  aristol  powder. 


FIG.  141.  FIG.  142. 

CORBECTION  OF  MALposED  AURICLES.     (Author's  case.) 

A  pad  of  gauze  is  placed  over  each  ear  and  a  bandage 
applied  around  the  head  to  protect  the  wounds  and  retain 
the  ears,  care  being  taken  not  to  tighten  too  tightly,  as 
this  occasions  great  pain  and  possible  pressure  erosion  of 
the  skin. 

The  dressing  should  be  changed  on  the  second  day,  as 
there  is  usually  some  soiling  of  the  dressings  at  the  lower 
angles  of  the  wounds.  They  are  again  powdered,  using 
the  pulverflator  preferably,  and  rebandaged. 

The  ears  will  be  found  to  lie  very  close  to  the  head  at 
this  time,  if  the  operation  has  been  properly  done.  Ante- 
riorly in  the  skin  of  the  concha  and  corresponding  to  the 
line  of  cartilage  exsection  will  be  found  a  crease  more  or 
less  discolored,  according  to  the  severity  of  injury  occa- 
sioned by  the  operation. 

This  should  give  the  surgeon  no  concern,  as  the  fold 
will  accommodate  itself  in  a  few  days.  There  may  be  a 


OTOPLASTY 


143 


persistence  of  the  fold  for  some  time,  however,  which,  if 
desirable,  can  be  corrected  by  a  small  secondary  opera- 
tion at  a  later  date.  The  author  has  never  experienced 
the  need  of  such,  however. 

The  patient  at  this  time  usually  bemoans  the  position 
of  his  ears,  and  should  be  assured  beforehand  what  was 
expected,  and  that  the  condition  is  only  temporary. 

The  dressings  after  this  can  be  repeated  every  second 
or  third  day,  as  may  be  required,  although  these  wounds 
heal  surprisingly  well. 

Moist  dressings  are  to  be  avoided  at  all  times,  they 
soften  the  edges  of  the  wound  and  prevent  primary  union. 

The  sutures  are  removed  on  the  ninth  or  tenth  day, 
whereafter  the  patient  may  be  allowed  to  go  without  the 
head  bandage,  but  is  strictly  instructed  to  replace  it  at 
night  with  a  band  of  muslin  three  inches  wide,  snugly 


FIG.  143.  FIG.  144. 

POSTERIOR  VIEW  OF  REPLACED  AURICLES. 

pinned  around  the  head  to  prevent  the  ears  from  being 
injured  or  torn  away  from  their  new  attachment  by  sud- 
den movements  during  sleep.  This  bandage  should  be 
worn  at  night  for  at  least  a  month. 


When  only  a  part  of  the  ear  is  overprominent  the 
operation  undertaken  should  in  the  main  be  according  to 
the  methods  just  described,  the  incisions  being  changed 
in  extent  accordingly. 

In  the  illustrations  above,  Figs.  143  and  144,  are 
shown  the  posterior  view  of  the  ears  before  and  after 
operation.  At  no  time  should  the  ears  be  placed  too 
closely  to  the  head,  as  is  often  peculiarly  requested  by  the 
patient,  as  it  gives  an  unnatural  appearance  and  predis- 
poses toward  the  collection  of  filth  in  the  sulcuses  that  is 
hard  to  remove.  The  distance  from  the  head  to  the  outer 
rim  of  the  ear  should  be  about  half  an  inch  at  its  widest 
part. 


CHAPTER    XI 

CHEILOPLASTY 
(Surgery  of  the  Lips) 

THIS  branch  of  plastic  surgery  has  to  do  with  the 
correction  of  deformities  of  the  lips.  These  deformities 
usually  involve  one  lip  only,  and  are  dependent  upon 
direct  traumatism,  operative  interference  in  the  extirpa- 
tion of  malignant  growths,  particularly  carcinomata,  the 
correction  of  cicatricial  disfigurement  following  tubercu- 
lar or  syphilitic  ulceration  or  congenital  faults,  commonly 
met  with  in  harelip. 

Operations  for  the  latter  condition  have  usually  been 
considered  under  a  separate  heading,  but  since  the  restor- 
ative  procedures    involve  methods   purely 
plastic  they  are  included  under  this  their 
proper  classification. 


FIG.  146. — BEINL  HARELIP  CLAMP. 

Owing  to   the  great   number   of  blood 
vessels  in  the  lips,  it  is  advisable  to  resort 

FIQ.  145. 

BURCHABDT  COM-  to  the  bloodless  method,  where  the  defect 
pREssioN  FOR-  t0  be  corrected  involves  more  than  the  su- 
perficial structure.    This  is  accomplished: 
1.  By  compressing  the  coronary  arteries  at  both  an- 
gles of  the  mouth  by  digital  pressure,  suitable  clamps  or 
11  145 


146     PLASTIC   AND    COSMETIC    SURGERY 

compression  forceps.  The  fenestrated  oval  forceps,  illus- 
trated in  Fig.  145,  and  designed  by  Burchardt,  or  the 
harelip  clamp  of  Beinl,  Fig.  146,  will  be  found  to  meet 
the  purpose  well,  the  latter  having  a  sliding  lock  by 
which  the  pressure  upon  the  tissue  can  be  regulated  to 
a  nicety. 

2.  By  clamping  off  the  site  of  operation  with  specially 
made  cutisector  forceps.    Its  smooth  parallel  jaws  should 
be  curved  outward,  so  that  the  diseased  area  can  be  fully 
excluded  by  their  concavities. 

3.  By  employing  the  indirect  ligature  of  Langenbuch. 
This  is  accomplished  by  including  the  site  of  operation 
with  several  strong  silk  threads  firmly  tied  in  loops  upon 
the  skin  surface,  each  loop  including  a  given  amount  of 
tissue,  the  next  encroaching  upon  it  up  to  the  center  of 
this  area,  and  so  on  until  the  entire  site  is  rendered 
anemic.    The  advantage  of  this  method  is  that  with  the 
anemia  a  certain  amount  of  anesthesia  is  produced  at  the 
same  time;  a  fact  to  be  remembered  when  the  patient  is 
to  be  operated  under  local  anesthesia,  the  anemia  en- 
hancing the  efficacy  of  the  latter. 

HARELIP 

A  congenital  defect  of  the  upper  lip  caused  by  the 
lack  of  proper  union  of  the  maxillary,  globular,  and 
frontonasal  processes  in  embryo.  Treves  states  that 
from  the  buccal  aspect  of  the  maxillary  process  of  either 
side  the  palatal  processes  arise,  passing  inward  to  com- 
bine with  each  other  to  form  the  soft  palate  and  all  of 
the  hard  palate,  except  the  intermaxillary  portion,  and 
that  from  this  same  source  are  formed  the  cheeks,  the 
outer  or  lateral  parts  of  the  upper  lip,  and  the  superior 
maxillary  bones,  while  the  external  nose,  the  ethmoid, 
the  vomer,  the  median  portion  of  the  upper  lip,  and  the 
intermaxillary  or  os  incisivum  are  derived  from  the 
frontonasal  process. 


CHEILOPLASTY  147 

The  fact  that  these  centers  of  development  are  con- 
cerned in  the  formation  of  the  parts  involving  harelip 
accounts  for  the  position  of  the  cleft  in  the  lip  as  being 
unilateral  or  bilateral,  and  rarely  if  ever  median  or  inter- 
maxillary. 

CLASSIFICATION  OF  HARELIP  DEFORMITIES 

Six  varieties  of  harelip  deformity  are  recognized  by 
Rose,  but  herein  only  five  classes  of  these  will  be  consid- 
ered, one  of  which,  the  first,  is  so  rare  that  its  occurrence 
is  practically  denied. 

For  all  purposes  in  surgery  of  the  face,  in  which  cos- 
metic effects  are  sought,  the  author  considers  the  follow- 
ing classification  to  answer  fully : 

1.  Median  or  intermaxillary  cleft. 

2.  Single  and  double  cleft. 

3.  Facial  cleft. 

4.  Buccal  cleft. 

5.  Mandibular  cleft. 

1.  Median  or  Intermaxillary  Cleft. — As  has  been  said,  the 
first  variety  of  this  form  of  lip  deformity  is  very  rarely 
met  with.  It  consists  of  a  cleft  in  the  median  third  of 
the  upper  lip,  more  rarely  associated  with  the  absence  of 


FIG.  147. — MEDIAN  CLEFT.  FIG.  148. — MEDIAN  CLEFT  WITH  RHINO- 

(Engle's  case.)  PHYMIA.     (Trendelenburg's  case.) 

the  intermaxillary  bone  and  total  cleft  of  the  hard  and 
soft  palate.  In  fact,  the  entire  median  section  may  be 
absent  with  or  without  absence  of  the  intermaxillary  and 


vomer  bones  (Engle)  (see  Fig.  147).  Commonly,  how- 
ever, the  cleft  involves  only  a  part  of  the  filtrum  of  the 
lip,  although  Witzel  speaks  of  a  case  in  which  the  lip 
assumed  the  form  of  a  dog's  nose,  the  cleft  extending 
upward,  completely  dividing  the  nares  from  one  an- 
other, or  the  entire  nose  may  be  divided  in  its  median 
line. 

When  the  cleft  involves  the  hard  parts — that  is,  the 
intermaxillary  bone  and  the  hard  palate — it  is  said  to  be 
total. 

2.  Single  and  Double  Cleft, — The  second  variety  in  the 
above  classification  is  by  far  the  most  common,  and  is 
often,  therefore,  termed  ordinary.  In  this  there  exists 
either  a  unilateral  or  bilateral  cleft  of  the  lip  of  varying 
degree,  depending  upon  the  involvement  of  the  tissue 
affected.  It  is  not  unusual  to  find  fissures  in  these  cases 
extending  through  the  alveolar  arch  and  the  hard  and 
soft  palate. 

This  fissure  or  cleft  is  always  found  on  one  side  of 
the  median  line,  while  in  the  soft  palate  it  is  median. 

Most  unilateral  clefts  of  the  lip  will  be  found  to  be  in 
the  left  outer  third.  They  are  more  common  in  the  male 
child. 

The  degrees  of  deformity  of  the  soft  parts  in  the 
unilateral  variety  are  shown  in  Figs.  149  to  151,  respect- 


FIG.  149. 


FIG.  150. 
TYPES  OF  UNILATERAL  CLEFT. 


FIG.  151. 


ively,  representing  the  first,  second,  and  third  degrees  of 
the  cleft  deformity,  according  to  the  involvement  of  the 
lip  tissue.  In  first  degree  are  included  small  notches  in 
the  prolabium  only  or  extending  upward  somewhat  above 


149 


its  margin,  but  not  involving  the  entire  lip.  In  the  sec- 
ond degree  both  the  vermilion  border  and  the  lip  are 
divided,  while  in  the  third  degree  the  cleft  extends  into 
the  nose  with  an  absence  of  part  of  the  lip  structure 
itself. 

Since  the  deformity  in  the  division  under  discussion 
is  so  commonly  met  with  it  will  be  considered  fully  under 
its  operative  correction. 

3.  Facial  Cleft. — The  third  class  of  deformity  includes 
either  unilateral  or  bilateral  fissure  of  the  face. 

In  the  unilateral  variety  the  cleft  usually  begins  at 
the  outer  section  of  the  upper  lip,  involving,  as  a  rule, 
only  the  soft  parts,  extending  upward  and  irregularly 
around  the  ala3  of  the  nose  to  the  inner  canthus  of  the 
eye,  or  going  even  beyond  the  orbit  and  over  the  fore- 


FIG.  152. — UNILATERAL  FACIAL  CLEFT. 
(Hasselmann.) 


\ 


FIG.  153. — BILATERAL  FACIAL  CLEFT. 
(von  Guersant.) 


head  as  far  as  the  hair  line.  An  illustration  of  such  a 
case  is  shown  in  Fig.  152. 

The  bilateral  form  of  this  facial  defect  is  rarely  met 
with.  A  case  reported  by  von  Guersant  is  shown  in 
Fig.  153. 

4.  Buccal  Cleft. — In  the  fourth  variety  the  deformity  in- 
volves the  cheeks,  the  fissures  extending  from  the  angles 
of  the  mouth  outward,  causing  an  enlargement  of  this 
natural  opening,  and  hence  this  defect  is  better  known  as 
macrostoma. 


150     PLASTIC   AND    COSMETIC    SURGERY 

It  may  affect  one  or  both  cheeks.  The  latter  is  eluci- 
dated in  Fig.  154. 

On  the  other  hand  there  may  exist  a  congenital  con- 
traction of  the  mouth  termed  mi- 
crostoma.  This  defect  is  rarely 
seen,  and  is  due  to  a  too  free 
union  of  the  maxillary  and  man- 
dibular  processes.  When  observed 
it  is  usually  associated  with  im- 
proper development  of  the  inferior 
maxillary  bones. 

5.  Mandibular  Cleft.— In  the  fifth 
class  the  cleft  is  to  be  found  in  the 
median  line  of  the  lower  lip.  This 

FIG.  154. — BUCCAL  FISSURE      _e  ji  i  i 

WITH  MACROSTOMA.  fissure,  though  extremely  rare,  may 
involve  only  the  soft  tissue  or  ex- 
tend to  the  inferior  maxillary  (Thorndike)  and  even  to 
the  tongue  (Wolfler). 

From  what  has  been  said  of  the  five  varieties  just 
mentioned  it  can  be  plainly  seen  that  the  defects  of  the 
second  class  are  the  most  common.  Since  the  correction 
of  such  involves  methods  of  an  extensive  technique  that 
can  be  followed  more  or  less  in  the  restoration  of  any 
of  the  above,  this  particular  subdivision  will  be  consid- 
ered fully,  but  only  to  the  extent  of  defects  of  the  soft 
parts,  leaving  the  osteoplastic  and  periosteoplastic  oper- 
ations to  be  studied  elsewhere. 

The  defects  that  have  to  do  with  facial  and  buccal 
clefts  will  be  more  specifically  mentioned  later  on  under 
Melo-  and  Stomatoplasty. 

THE  OPERATIVE  CORRECTION  OF  HARELIP 

The  correction  of  a  harelip  should  be  undertaken  as 
early  as  the  first  two  weeks  after  birth  in  the  healthy 
child.  If,  however,  the  infant  is  considered  too  delicate 
to  undergo  so  early  an  ordeal,  the  operation  should  be 
deferred  until  the  third  or  even  the  fifth  month.  At  any 


CHEILOPLASTY  151 

rate  the  operation  should  be  undertaken  as  early  as 
deemed  advisable,  since  the  closure  of  the  cleft  has  a 
desirable  effect  upon  the  ofttime  overprominent  inter- 
maxillary bone,  helps  to  approximate  its  lateral  borders, 
overcomes  the  later  depression  deformity  of  the  upper 
lip,  aids  its  natural  development,  and  permits  of  the  child 
suckling  the  breast — an  important  factor  in  the  proper 
nourishment,  since  the  defect  allows  only  of  feeding  with 
the  spoon,  the  child  being  unable  to  grasp  the  nipple  of 
the  breast  in  this  state.  Furthermore,  the  act  of  phona- 
tion  is  practically  entirely  perfected  by  an  early  opera- 
tion, and  rarely  if  ever  overcome  when  faulty  phonation 
has  been  established. 

Unilateral  Labial  Cleft 

The  restoration  of  an  unilateral  cleft  is  to  be  per- 
formed without  the  use  of  an  anesthetic.  The  child's 
arms  are  fastened  to  its  sides  with  several  turns  of  a  wide 
roller  bandage.  It  is  then  seated  upon  the  lap  of  the 
assistant,  who  holds  its  head  in  position,  compressing  the 
coronary  arteries  with  his  fingers  at  the  outer  sections 
of  the  upper  lip  at  the  same  time.  If  this  is  impractical, 
proper  forceps  can  be  employed,  as  already  mentioned. 
It  is  rarely  necessary  to  employ  the  direct-ligature 
method  heretofore  referred  to  in  this  class  of  operations. 
More  or  less  bleeding  always  accompanies  the  operation, 
the  child  usually  swallowing  what  enters  the  mouth  if 
not  sponged  up  repeatedly. 

To  facilitate  matters  the  child  can  be  anesthetized, 
chloroform  being  used.  In  this  case  the  patient  is  to  be 
placed  on  its  side,  the  head  being  fixed  in  a  dependent 
position  (Rose). 

This  gives  freer  drainage  of  the  bleeding  surfaces,  the 
blood  being  sponged  up  with  gauze  sponges  as  required, 
while  the  vessels  that  are  cut  can  be  tied  off  with  catgut 
ligatures  as  fast  as  they  are  divided. 

The  anesthetic  can  be  given  upon  a  small  sponge  held 


152      PLASTIC    AND    COSMETIC    SURGERY 

before  the  nostrils.  Infants  should  not  be  anesthetized, 
yet  in  older  children  it  is  almost  always  necessary. 

A  simple  freshening  of  the  edges  of  the  defect  with  the 
bistoury,  followed  by  suture,  does  not  give  a  desired 
cosmetic  effect,  hence  it  is  advisable  to  resort  to  methods 
intended  to  restore  the  lip  as  far  as  possible  to  its  nor- 
mal state. 

Nelaton  Method. — The  simplest  operation  for  a  cleft  of 
moderate  extent  not  involving  the  nare  is  that  of  Nelaton. 
He  divides  the  lip  above  the  angle  parallel  with  the  defect 
with  a  bistoury,  cutting  upward,  including  the  upper 
angle  which  allows  the  prolabium  surmounted  by  a  thin 
strip  of  skin  to  droop  downward  in  a  point. 


FIG.  155.  FIG.  156.  FIG.  157. 

NELATON  METHOD. 

The  lower  angle  of  the  wound  is  then  drawn  down- 
ward and  united  lengthwise  with  silkworm  gut  sutures, 
giving  to  the  prolabium  a  protrusion  or  tip,  which  even- 
tually retracts  and  causing  the  lip  to  assume  a  natural 
aspect. 

The  method  is  shown  in  Figs.  155-157. 

Fillebrown  Method. — Fillebrown  has  devised  a  method 
where  the  vermilion  border  of  the  lip  is  entirely  pre- 
served, as  in  the  preceding  operation.  His  method  can 
only  be  employed  where  the  cleft  is  not  extensive.  He 
commences  his  incision  at  the  red  border  at  the  outer 
left  line,  cutting  upward  and  inward  toward  the  median 
line  a  short  distance  (see  Fig.  158),  then  downward  to 
the  red  border  of  the  lip,  then  upward  and  outward  to 
the  right  of  the  median  line,  corresponding  to  the  incision 
just  made  to  the  left  of  the  median  line*  The  upper 


CIIEILOPLASTY 


153 


angle  of  the  cleft  is  now  drawn  down  by  its  red  border 
and  the  wound  sutured,  as  shown  in  Fig.  159.    This  oper- 


FIG.  158. 


FlLLEBROWN    METHOD. 


FIG.  159. 


ation  does  not  project  a  small  triangle  of  the  white  skin 
into  the  vermilion  border  and  gives  excellent  results. 

Von  Langenbeck,  Wolff,  and  Sedillot  Methods. — The  methods 
of  von  Langenbeck,  Wolff,  and  Sedillot  are  somewhat 
similar  to  that  of  Nelaton.  An  incision  is  made  slightly 


FIG.  160.  FIG.  161.  FIG.  162. 

VON  LANGENBECK-WOLFF-SEDILLOT  METHOD. 

above  the  prolabium,  following  the  angle  of  distortion 
and  reaching  outward  to  either  side  of  the  median  line 
almost  to  the  angle  of  the  mouth.  The  raw  edges  corre- 
sponding to  the  defect  are  brought  together  by  suture 
and  a  section  of  the  prolabium  is  removed  to  overcome 
its  overprominence,  but  not  enough  to  entirely  flatten  the 
vermilion  border  (see  Figs.  160-161).  The  latter  is  su- 
tured horizontally  to  such  part  of  the  angular  defect 
as  has  not  been  utilized  in  the  median  line,  and  also 


154      PLASTIC    AND    COSMETIC    SURGERY 

vertically  as  far  down  as  its  free  border,  as  sliown  in 
Fig.  162. 

Malgaigne  Method. — The  method  of  Malgaigne  differs 
in  technique  in  that  he  utilizes  a  semicircular  incision, 
which  is  made  to  include  the  upper  angle  of  the  defect. 


FIG.  163. 


FIG.  164. 
MALGAIGNE  METHOD. 


FIG.  165. 


Both  ends  of  this  incision  are  continued  horizontally  out- 
ward to  a  required  extent  (see  Fig.  163).  The  freed  pro- 
labial  flaps  are  drawn  downward,  as  in  Fig.  164,  and 
sutured  vertically,  as  shown  in  Fig.  165.  Two  retention 
sutures  are  shown  in  the  latter  figure  to  overcome  the 
tension  of  the  lips  post  operatio. 

The  semicircular  incision  should  be  preferred  when 
the  defect  will  permit  it,  since  the  unequal  lengths  of  the 
two  lip  halves  may  thereby  be  more  uniformly  approx- 
imated, while  the  prolabium  in  being  crowded  downward 
overcomes  the  notchlike  scar  so  common  with  the  verti- 
cal-incision method. 


FIG.   166. 


GHAFE  METHOD. 


FIG.   167. 


Grafe  Method. — This  method,  as  shown  in  Fig.  166,  is, 
therefore,  to  be  preferred  when  the  defect  is  one  of  the 


first  or  second  degree. 


CHEILOPLASTY 


155 


The  first  suture  is  to  be  placed  at  the  margin  of  the 
vermilion  border  and  the  skin,  so  that  the  unequal  sides 
are  placed  in  normal  apposition.  The  parts  are  sutured 
according  to  the  method  shown  in  Fig.  167. 

Mirault-Bruns  Method. — An  excellent  method  of  this  class 
is  that  of  Mirault-Bruns.  Their  operation  is  indicated  in 


FIG.   168. 


FIG.  169. 
MIRAULT  METHOD. 


FIG.  170. 


defects  of  extensive  degree,  and  usually  gives  excellent 
results.  As  in  the  former  method  a  semicircular  incision 
is  made  to  include  the  superior  angle,  and  two  other  inci- 
sions are  made  somewhat  as  shown  in  Fig.  168.  The 
wound  made  thereby  is  shown  in  Fig.  169.  The  inferior 
triangular  flap  of  one  side  is  utilized  to  restore  the  pro- 
labium,  the  whole  being  sutured,  as  shown  in  Fig.  170, 
care  being  taken  to  make  this  flap  of  sufficient  size  to 
give  stability  and  volume  to  the-  lower  margin  of  the  lip. 


FIG.  171. 


FIG.  172. 
GIRALDE  METHOD. 


FIG.  173. 


Giralde  Method. — This  method  is  intended  for  defects  of 
the  third  degree.  A  vertical  incision  frees  the  vermilion 
border  on  one  side,  while  an  angular  cut  on  the  opposite 
side  (see  Fig.  171)  allows  of  the  bringing  together  the  lip 
flaps  above  it.  The  wound  is  made  to  appear  somewhat 
as  in  Fig.  172,  and  is  sutured,  as  depicted  in  Fig.  173. 


156     PLASTIC    AND    COSMETIC    SURGERY 

Kbnig  Method. — Konig  advocates  two  vertical  incisions 
which  dispose  of  the  cicatrized  borders  of  the  defect.  A 
slanting  incision  is  added  at  both  sides  to  free  the  pro- 
labium  (see  Fig.  174),  giving  a  wound  when  drawn  in 


FIG.  174. 


FIG.  175. 
KONIG  METHOD. 


FIG.  176. 


position,  as  shown  in  Fig.  175.  In  suturing  the  wound 
the  vermilion  border  flaps  are  turned  downward  as  much 
as  possible  to  restore  the  contour  of  the  prolabium.  The 
sutures  are  placed  as  shown  in  Fig.  176. 

Maas  Method. — Maas  has  deviated  from  the  above 
method  somewhat,  as  is  shown  in  Fig.  177,  by  making 
one  of  the  prolabial  flaps  much  larger  than  the  other. 
His  operation  is  applicable  to  defects  of  maximum  extent. 
The  lip  wounds  are  thereby  made  to  appear  as  in  Fig. 


FIG.  177. 


FIG.  178. 
MAAS  METHOD. 


FIG.   179. 


178,  and  the  sutures  are  applied  as  in  Fig.  179,  with  an 
advantage  of  leaving  a  smaller  sutured  wound  to  heal  by 
primary  union. 

Haagedorn  Method. — Haagedorn's  method  does  not  differ 
much  from  the  above.  The  incisions  are  shown  in  Fig. 
180,  the  appearance  of  the  freed  margins  in  Fig.  181,  and 


CHEILOPLASTY 


157 


the  sutured  wound  in  Fig.  18:2.  The  prolabial  flaps  are 
somewhat  alike  in  size  in  this  operation,  in  whieh  it  dif- 
fers only  in  the  method  just  considered. 


FIG.  180. 


FIG.   181. 
HAAGEDORN  METHOD. 


FIG.  182. 


Geuzmer  Method. — Geuzmer  so  incised  the  cicatrized  de- 
fect that  a  small  prolabial  flap  is  formed  from  the  median 
border  and  a  larger  one  from  the  lateral,  the  very  oppo- 
site of  the  Haagedorn  technique. 

Dieffenbach  Method. — To  facilitate  the  mobility  of  the 
lip  flaps,  Dieffenbach  has  added  two  additional  incisions 
on  either  side  of  the  nose,  in  circular  fashion,  encircling 
the  ala3  of  the  nose,  as  shown  in  Fig.  183.  This  procedure 
is  hardly  ever  necessary  in  harelip,  and  truly  applies  to 
the  restoration  of  a  considerable  loss  of  tissue  of  the 


FIG.  183. 


FIG.  184. 
DIEFFENBACH  METHOD. 


FIG.  185. 


upper  lip  occasioned  by  the  extirpation  of  cancerous 
growths,  although  clefts  of  the  median  variety  might  be 
corrected  thereby. 

The  wound  thus  formed  appears  as  in  Fig.  184.  The 
sutures  are  placed  as  in  Fig.  185. 

Instead  of  the  semicircular  incisions  a  horizontal  inci- 
sion on  either  side  of  the  cleft  may  be  made  just  below 


158      PLASTIC   AND    COSMETIC    SURGERY 

the  nose  with  the  same  object  in  view,  the  wound  being 
sutured  in  angular  form  similar  to  the  method  of 
Nelaton. 

Congenital  Bilateral  Labial  Cleft 

The  occurrence  of  bilateral  cleft  of  the  lip  is  much 
rarer  than  the  variety  just  described.  According  to 
Fahrenbach,  out  of  210  cases  he  found  only  59  of  some 
degree  of  the  bilateral  form. 

The  degrees  of  deformity  have  alread)T  been  men- 
tioned. 

The  correction  of  these  types  of  fissure  is  very  sim- 
ilar to  that  of  the  single  cleft  variety  except  that  the  oper- 
ations for  the  latter  are  simply  duplicated  on  the  oppo- 
site side. 

Particularly  is  this  true  in  cases  of  the  first  degree, 
while  in  the  severer  forms,  modifications  of  such  methods 
as  have  been  described  must  be  resorted  to,  according  to 
the  nature  and  extent  of  the  defect. 

It  must  always  be  the  object  of  the  surgeon  to  save 
as  much  of  the  presenting  tissues  as  is  possible,  to  avoid 
traction  on  the  tissues  and  to  overcome  the  consequent 
thinning  out  of  the  entire  upper  lip  or  the  flattening  so 
often  seen  in  the  lips  of  these  patients. 

The  correction  of  this  flattening  of  the  lip  following 
operations  for  the  restoration  of  the  lip  will  be  considered 
later. 

The  following  operations  for  the  correction  of  bilat- 
eral cleft  may  be  regarded  as  fundamental : 

Von  Esmarch  Method. — Von  Esmarch  advocates  an  inci- 
sion circling  the  central  peninsula  just  sufficient  to  re- 
move the  bordering  cicatrix.  Both  lateral  borders  are 
vivified  along  the  limit  of  the  vermilion  borders  (see 
Fig.  186).  He  advises  suturing  the  mucous-membrane 
flaps  which  he  retroverts  to  form  a  basement  membrane, 
upon  this  he  slides  the  skin  flaps,  and  sutures  them  as 
shown  in  Fig.  187. 


159 


The  best  results  are  obtained  when  the  lip  is  suffi- 
ciently detached  from  the  jaw  by  deep  incisions  beginning 
at  the  duplicature  of  the  mucous  membrane.  This  in- 


Fic;.   ISO.  FIG.  187. 

VON  ESMARCH  METHOD. 

sures  the  necessary  mobility,  and  is  considered  by  him 
the  most  important  step  in  the  operation. 

Maas  and  von  Langenbeck  Methods. — Maas  and  von  Lan- 
genbeck  vivify  the  median  peninsula  in  square  fashion, 
as  shown  in  Fig.  188,  and  suture  the  fresh  margins  of  the 
flaps,  as  shown  in  Fig.  189,  according  to  Fig.  190. 


FIG.   188. 


FIG.   189. 
MAAS  METHOD. 


FIG.   190. 


Haagedorn  Method. — Haagedorn's  method  is  very  simi- 
lar to  the  above  except  that  in  cutting  square  the  inferior 
border  of  the  median  portion  he  fashions  it  into  -a  tri- 
angular form,  with  the  object  of  giving  to  the  prolabium 
the  tiplike  prominence  found  in  the  normal  lip,  and  also 
avoiding  the  cicatricial  notch  obtained  with  the  direct 
suturing  of  the  vermilion  border  on  a  line  with  its  infe- 
rior limitation.  The  various  steps  of  his  method  are 
shown  in  Figs.  191,  192,  193. 


160 


If  there  be  considerable  absence  of  lip  tissue  lie  ad- 
vises making  two  lateral  incisions  sufficient  to  overcome 


C 


FIG.  191. 


FIG.  192. 
HAAGEDORN  METHOD. 


FIG.   193. 


the  tension  on  the  parts.  These  secondary  wounds  are 
allowed  to  heal  by  granulation. 

Simon  Method. — Simon  utilizes  two  curved  lateral  inci- 
sions encircling  the  alae  of  the  nose.  This  permits  of  a 
ready  juxtaposition  of  the  lateral  flaps  (see  Fig.  194). 
The  two  flaps  are  sewn  to  the  median  flap  (see  Fig.  195) 
and  are  allowed  to  heal  into  place,  the  secondary  wounds 
healing  by  granulation. 

When  this  has  been  accomplished,  a  later  operation  is 
undertaken  to  correct  the  prolabial  border,  the  incision 
for  which  and  the  disposition  of  the  suture  are  shown 
in  Fig.  196. 


FIG.  194. 


FIG.   195. 
SIMON  METHOD. 


FIG.   196. 


This  operation  is  useful  only  in  older  children,  and 
has  the  disadvantage  of  requiring  a  secondary  interfer- 
ence. The  results  are  not  as  good  as  those  obtained 
with  the  operations  mentioned  previously,  leaving,  be- 
sides, a  disfiguring  cicatrix  at  either  border  of  the  alas, 
a  serious  objection,  especially  to  the  cosmetic  surgeon. 


161 


POSTOPERATIVE  TREATMENT  OF  HARELIP 

When  the  operation  has  been  performed  in  the  infant 
the  wound  is  simply  kept  clean  by  the  local  use  of  warm 
boric-acid  solutions  and  the  mouth  is  cleansed  from  time 
to  time  by  wiping  it  out  with  a  piece  of  gauze  dipped  into 
the  solution. 

Children  do  not  bear  dressings  of  any  kind  well,  al- 
though Heath  employs  strips  of  adhesive  plaster  to  draw 
the  cheeks  together  to  relieve  tension  on  the  sutures. 

To  keep  the  child  from  tearing  or  picking  at  the 
wound  Littlewood  advises  fixing  both  elbows  in  the  ex- 
tended position  with  a  few  turns  of  a  plaster-of-Paris 
bandage. 

Everything  should  be  done  to  keep  the  child  quiet,  as 
crying  often   results   in  separating  the  wounds.     This 
is  accomplished  by  giving 
it   milk   immediately  after 
the  operation.    The  mother 
must  ply  herself  closely  in 
soothing  the  child  by  carry- 
ing it  about,  rocking,  and 
feeding  it. 

The  feeding  should  be 
done  with  the  spoon.'  Dark- 
colored  stools  containing 
swallowed  blood  will  be 
passed  in  the  first  twenty- 
four  hours;  to  facilitate 
this  a  mild  laxative,  such 
as  sirup  of  rhei,  can  be 
given. 

In  older  children  a  compressor  can  be  applied  to  the 
head.  That  of  Hainsley,  shown  in  Fig.  197,  answers 
very  well,  yet  adhesive  plaster  dressings,  if  carefully  re- 
moved later,  are  most  commonly  used. 

The  sutures  may  be  removed  as  early  as  the  sixth  day, 
12 


Fio.  197. — HAINSLEY  CHEEK 
COMPRESSOR. 


162      PLASTIC   AND    COSMETIC    SURGERY 

but  it  is  best  to  release  the  wound  sutures  about  this 
time,  and  leave  the  tension  sutures  for  two  or  three  days 
later. 

It  often  happens  that  the  entire  wound  has  not  healed 
by  primary  union,  if  this  occurs  and  sufficient  union  has 
taken  place  in  part  of  the  lip,  the  wound  should  be  allowed 
to  heal  by  granulation. 

Should  the  entire  wound  separate  on  the  removal  of 
the  sutures,  the  operator  may  attempt  to  secure  healing 
of  the  wound  by  applying  a  secondary  suture  to  bring 
the  granulating  surfaces  together,  although  little  is 
gained  by  this  procedure  as  a  rule. 

If  reoperation  becomes  necessary,  it  should  not  be 
undertaken  before  six  weeks  or  more  have  elapsed.  At 
any  rate  not  before  the  lip  tissues  have  returned  to  their 
normal  state.  Inflamed  tissues  do  not  retain  sutures  well. 

It  usually  becomes  necessary  to  perform  small  cos- 
metic operations  after  the  healing  of  harelip  wounds. 
Those  should  not  be  undertaken  until  the  child  is  of  such 
age  as  to  insure  a  perfect  result. 

SUPERIOR  CHEILOPLASTY 

Plastic  operations  for  the  reconstruction  of  the  upper 
lip  are  not  met  with  often  in  surgery,  except  in  connec- 
tion with  the  various  forms  of  harelip.  When  the  latter 
is  not  the  cause,  deficiencies  of  the  upper  lip  are  due  to 
the  ulcerative  forms  of  syphilis,  and  are  occasioned  by 
the  ablation  of  epithelioma  and  carcinoma  or  the  result 
of  burns  or  lupus.  Rarely  the  surgeon  will  meet  with 
such  a  defect  caused  by  dog  bite  or  other  traumatisms 
due  to  direct  violence,  as  in  railroad  or  automobile  acci- 
dents. 

CLASSIFICATION  OF  DEFOEMITIES  OF  UPPER  LIP 

Berger  has  classified  three  degrees  of  this  deformity, 
according  to  its  severity,  to  wit : 


CHEILOPLASTY  163 

1.  The  skin  only  is  destroyed  and  the  mucosa  remains. 

2.  The  mucosa  has  been  partially  destroyed  with  the 
skin,  but  a  part  of  the  free  border  of  the  lip  remains  and 
is  attached  to  the  cicatrix. 

3.  All  the  parts  which  make  up  the  lip  have  been  de- 
stroyed, and  there  remains  neither  skin,  mucosa,  mus- 
cles, nor  the  prolabium. 

The  loss  of  substance  of  varying  degree  may  involve 
either  of  the  outer  thirds  or  the  median  position  of  the 
lip,  or  its  entire  structure.  For  a  more  explicit  classifica- 
tion the  author  divided  these  defects  into: 

(a)  Unilateral  defect  of  the  first,   second,  or  third 
degree. 

(b)  Bilateral  defect  of  the  first,  second,  or  third  de- 
gree. 

(c)  Median  defect  of  the  first,  second,  or  third  degree. 

(d)  Total  loss  of  upper  lip. 

This  same  classification  applies  to  the  defects  of  the 
lower  lip. 

OPERATIVE  CORRECTION  OF  DEFORMITIES  OF  UPPER  LIP 

When  the  deformity  is  either  of  the  first  or  second 
degree,  one  or  the  other  of  the  operations  for  the  restora- 
tion of  congenital  cleft  just  considered  may  be  employed. 
When  these  are  impracticable  other  methods  must  be 
resorted  to. 

Bruns  Method. — Bruns  advocates  making  two  lateral 
flaps  from  the  cheeks,  as  shown  in  Fig.  198.  He  preserves 
the  inferior  margin  of  these  flaps,  which  contain  a  cica- 
tricial  border  which  must  take  the  place  of  the  prolabium. 
This  border  can,  however,  be  made  up  of  the  vermilion 
border  of  the  lower  lip,  as  shown  later  in  the  perform- 
ance of  stomatoplasty,  to  establish  a  better  cosmetic 
effect. 

The  rectangular  cheek  flaps  are  sutured,  as  in  Fig. 
199,  leaving  two  small  triangular  wounds  at  either  side 
of  the  alae  to  heal  by  granulation. 


164     PLASTIC    AND    COSMETIC    SURGERY 

The  cheek  flaps  referred  to  must  be  dissected  up  from 
the  bone,  and  be  rendered  as  mobile  as  possible  for  a  suc- 
cessful issue. 


FIG.  198. 


FIG.  199 


BRUNS  METHOD. 


Dieffenbach  Method. — The  method  of  Dieffenbach  is  very 
similar  to  the  above.  It  has  been  described  on  page  157. 
In  this  the  lateral  flaps  are  made  by  two  curved  incisions 
encircling  the  alse  of  the  nose.  Should  these  be  insuffi- 
cient, two  other  curved  incisions  are  added,  as  shown  by 
the  dotted  lines  in  Fig.  183. 

Sedillot  Method. — Sedillot  also  employs  two  rectangular 
flaps,  but  he  cuts  them  from  the  region  of  the  chin  (see 
Fig.  200). 

The  advantage  of  this  method  lies  in  the  fact  that 
these  flaps  are  lined  throughout  with  mucous  membrane, 


FIG.  200. 


FIG.  201. 


SEDILLOT  METHOD. 


as  the  incisions  are  made  entirely  through  the  tissues 
involved,  beginning  at  the  angle  of  the  mouth  and  extend- 


CHEILOPLASTY 


165 


ing  downward  to  the  limitation  of  the  buccal  fold  inte- 
riorly. 

The  flaps  are  twisted  into  position  and  sutured,  as 
shown  in  Fig.  201.  The  mucous  membrane  of  the  inferior 
border  is  dissected  up  to  a  required  extent  and  turned 
outward  and  stitched  to  the  skin  margin  without  to  pro- 
vide the  prolabium.  This  is  an  important  matter  not 
only  for  cosmetic  reasons,  but  especially  because  such 
mucous-membrane  lining  overcomes  to  a  great  degree 
the  objectionable  cicatricial  contraction  of  this  free 
border. 

In  certain  cases  the  mucous-membrane  grafts  of 
Wolfler  may  be  employed  to  cover  the  raw  edge  of  these 
newly  made  lips,  or  the  Thiersch  method  of  skin-grafting 
might  be  employed  with  the  same  object. 

Where  the  defect  is  unilateral,  as  is  usually  the  case, 
a  single  cheek  or  chin  flap  need  only  be  employed,  and 
this  lined  with  mucous  membrane. 

Buck  Method. — Buck,  in  such  unilateral  defects,  employs 
an  interolateral  rectangular  flap.  It  contains  a  part  of 
the  lower  lip  and  its  ver- 
milion border.  This  flap 
is  twisted  upward,  so  that 
its  outer  and  free  end 
comes  in  apposition  at  or 
near  the  median  line  as 
may  be,  with  the  remain- 
ing half  of  the  upper  lip. 

This  half  of  the  lip  is 
freely  liberated  by  divid- 
ing the  buccal  mucous  membrane  along  the  reflecting 
fold.  Should  the  vermilion  border  be  contracted  upward 
along  the  median  cicatricial  line  it  is  carefully  cut  away 
from  the  lip  proper  down  to  its  normal  margin.  This 
strip  is  retained  until  the  flap  taken  from  the  under  lip 
is  brought  into  position,  when  it  is  neatly  sutured  to  the 
prolabium  thus  brought  into  apposition.  If  there  be  a 


FIG.  202. — BUCK  METHOD. 


166      PLASTIC    AND    COSMETIC    SURGERY 

redundancy  of  the  freed  prolabimn  after  the  median 
sutures  have  been  applied  it  is  cut  away. 

The  secondary  defect  in  the  cheek  caused  by  the  rota- 
tion of  the  flap  is  closed  by  suturing  the  raw  surfaces 
together. 

The  resulting  mouth  will  be  much  smaller  than  nor- 
mal, having  a  puckered  appearance.  A  secondary  oper- 
ation, mentioned  later,  is  employed  to  correct  this. 

Estlander-Abbe  Method. — Estlander  and  Abbe  employed  a 
transplantation  flap  of  triangular  form  taken  from  the 
lower  lip  to  restore  median  defects  of  the  upper  lip, 


FIG.  204.  FIG.  205. 

ESTLANDER  METHOD. 

whether  due  to  a  deficiency  of  the  latter  following  harelip 
operation  or  the  extirpation  of  a  malignant  growth. 

Where  the  tissues  operated  upon  warrant  such  pro- 
cedure this  operation  will  give  excellent  results,  leaving 
the  mouth  almost  normal  in  shape  and  size. 

The  lower  pedunculated  flap  is  made  by  cutting 
directly  through  the  entire  thickness  of  the  lip,  includ- 
ing the  prolabium  at  A  (Fig.  203),  and  downward  toward 
the  median  line  to  the  point  B,  thence  upward  to  the 
margin  of  the  vermilion  border  at  G,  leaving  the  latter 
to  form  the  pedicle  of  the  flap  F.  The  defect  is  freshened 
by  either  a  median  incision,  D,  E,  or  the  ablation  is  made 
in  triangular  form. 

The  flap  F  is  now  rotated  upward  and  sutured  into 
the  upper  lip,  as  shown  in  Fig.  204.  The  triangular  de- 
fect thus  made  in  the  lower  lip  is  sutured  along  the 
median  line. 


CHEILOPLASTY  167 

The  prolabial  pedicle  of  the  flap  F  is  not  divided 
until  about  the  eighth  day,  when  the  vermilion  borders 
of  both  the  upper  and  lower  lips  are  restored  by  the  aid 
of  the  free  stump  ends,  which  are  neatly  sutured  into  posi- 
tion, as  shown  in  Fig.  205. 

This  operation  may  also  be  used  in  the  unilateral 
type  of  defect.  It  will  be  described  in  the  operation 
of  the  lower  lip,  where  it  is  more  frequently  employed 
than  in  connection  with  faults  of  the  upper  lip. 

INFERIOR   CHEILOPLASTY 

Apart  from  harelip  operation,  those  for  the  separa- 
tion of  the  lower  lip  are  the  most  common  about  the 
mouth.  This  is  due  in  a  great  measure  to  the  fact  that 
malignant  growths  so  frequently  attack  this  part  of  the 
human  economy  and  almost  exclusively  in  the  male.  Out 
of  sixty-one  cases  von  Winiwarter  found  only  one  female 
thus  affected.  It  has  not  been  determined  whether  the 
habit  of  pipe  smoking  has  been  a  factor  in  establishing 
this  unequal  proportion,  yet  it  is  acceded  to  be  the  fact,  so 
much  so  that  neoplasms  of  the  lip  in  men  have  been  com- 
monly termed  smoker's  cancer. 

The  ulcerative  forms  of  syphilis  and  tuberculosis 
seem  to  be  met  with  more  in  the  lower  than  in  the  upper 
lip ;  likewise  is  this  true  of  burns  and  acute  traumatisms. 

Defects  in  the  lower  lip  are,  therefore,  due  principally 
to  the  extirpation  of  carcinomata  or  other  malignant 
growths  and  less  frequently  to  the  other  causes  men- 
tioned. 

The  classification  and  extent  of  such  involvement  has 
already  been  referred  to. 

In  operations  intended  to  extirpate  a  growth  of  malig- 
nant nature  the  incisions  should  be  made  sufficiently  dis- 
tant from  the  neoplasm  to  insure  of  unaffected  or  unin- 
volved  tissue  to  avoid  a  recurrence  of  the  disease. 

These  growths  appear  at  first  in  wartlike  formation, 


1(58   PLASTIC  AND  COSMETIC  SURGERY 

becoming  thicker  in  time,  and  bleeding  readily  upon  inter- 
ference. They  seem  to  develop  horizontally,  and  invari- 
ably in  a  direction  toward  the  angle  of  the  mouth.  There 
is  more  or  less  involvement  of  the  lymphatic  glands, 
especially  of  the  submaxillary,  quite  early  in  the  attack. 

An  early  extirpation  of  such  growths  is  to  be  recom- 
mended, and  while  it  is  true  there  may  be  a  question  of 
primary  syphilitic  induration  instead  of  the  malignant 
variety  no  harm  is  done  if  the  diseased  area  be  at  once 
excised. 

This  is  especially  true  of  patients  beyond  the  thir- 
tieth year.  When  such  indurations  occur  before  that  age 
the  patient  may  be  put  under  a  proper  course  of  treat- 
ment to  determine  the  nature  of  the  infiltration  for  a 
period  of  three  or  four  weeks ;  if  this  does  not  resolve  it 
operative  measures  should  be  resorted  to.  It  is  to  be 
remembered  that  syphilitic  induration  may  involve  the 
upper  as  frequently  as  the  lower  lip,  a  fact  not  as  likely 
referable  to  cancer. 

In  sixty-seven  cases  reported  from  Billroth's  Clinic 
there  were  sixty-five  cases  of  carcinoma  of  the  lower 
lip  and  only  two  of  the  upper.  Yet  this  proportion 
hardly  applies  to  the  experience  of  most  surgeons.  The 
age  factor  is  not  to  be  overlooked. 

The  author  does  not  mean  to  claim  that  the  differ- 
ential diagnosis  of  these  diseases  is  at  all  difficult,  yet 
in  patients  beyond  the  admissible  age  early  and  radical 
treatment  should  not  be  neglected,  considering  what 
great  amount  of  misery  and  suffering,  not  to  mention  dis- 
figurement, can  be  overcome  by  prompt  action. 

Usually  these  neoplasms,  when  superficial,  are  found 
directly  in  the  prolabium,  are  unilateral,  and  occupy  a 
place  midway  between  the  angle  of  the  mouth  and  the 
median  line  of  the  lip. 

Richerand  Method. — Very  small  or  superficial  neoplasms 
may  be  removed  by  lifting  up  the  growth  with  a  fixation 
forceps  and  cutting  away  the  convexity  so  established  as 


CHEILOPLASTY 


169 


deeply  as  necessary  with  the  half-round  scissors,  or  the 
faulty  area  is  neatly  outlined  in  spindle  form  (Riche- 
rand)  with  the  bistoury,  as  in  Fig.  206,  and  then  excised 
according  to  the  method  selected  by  the  operator. 


FIG.  206. 


RICHEBAND  METHOD. 


FIG.  207. 


The  wound  is  sutured  horizontally,  as  shown  in  Fig. 
207. 

If  the  neoplasm  or  defect  is  of  a  more  extensive  form, 
involving  most  or  all  of  the  prolabium,  the  entire  area, 
including  the  necessary  allowance  of  healthy  structure, 
may  be  raised  up  by  a  clamp,  as  shown  in  Fig.  208,  and 
excised.  The  mucous  membrane  from  the  anterior  sur- 


FIG.  208.  Fia.  209. 

EXTIRPATION  OF  ENTIRE  VERMILION  BORDER. 

face  of  the  lip  is  then  brought  forward  and  sutured  to  the 
skin  margin,  as  in  Fig.  209.  The  disfigurement  in  this 
operation  is  surprisingly  little,  and  the  mucous  mem- 
brane thus  everted  takes  on  the  appearance  of  the  ver- 
milion border  of  the  lip  in  a  short  time. 

Celsus  Method. — When  the  neoplasm  has  become  more 
than  superficial,  or  the  defect  or  deformity  involves  more 
than  the  prolabium,  it  must  be  ablated  by  a  wedge-shaped 
incision,  the  base  upward  including  the  vermilion  bor- 


170     PLASTIC    AND    COSMETIC    SURGERY 

der  and  the  apex  extending  downward  upon  the  anterior 
chin. 

This  is  best  performed  by  piercing  the  tissue  with  a 
sharp  bistoury,  the  blade  penetrating  the  mucosa,  while 
an  assistant  compresses  the  coronary  vessels  with  his 
fingers  at  either  angle  of  the  mouth. 

The  incision  must  be  made  well  into  the  healthy  tissue, 
or  at  least  1  cm.  from  the  boundary  of  the  defect.  The 
incision  is  made,  as  outlined  in  Fig.  210,  from  below  up- 
ward while  the  operator  draws  up  the  triangular  mass 
to  be  removed  with  the  fingers  of  his  left  hand.  The  same 


FIG.  210.  FIG.  211. 

CELSUS  METHOD  WITH  ADDITIONAL  HORIZONTAL  INCISIONS. 

method  is  followed  on  the  other  side.  The  wound  mar- 
gins are  then  to  be  examined  microscopically  for  any  sign 
of  malignant  involvement.  If  there  be  any  it  should  at 
once  be  removed,  irrespective  of  the  size  of  the  wound 
occasioned  thereby.  For  this  reason  the  area  excised 
may  be  so  large  as  to  prevent  the  ready  apposition  of  the 
raw  edges.  Should  this  occur,  the  lip  halves  may  be  made 
more  mobile  by  adding  a  horizontal  incision  continuous 
from  the  angle  of  the  mouth  outward  and  over  the  cheek, 
as  shown  in  the  line  A,  C. 

A  single  incision  for  a  unilateral  defect  and  one  on 
either  side  for  a  median  excision,  as  shown  by  the  lines 
A,  C,  and  B,  C,  in  the  same  figure. 

This  operation  is  known  as  the  Celsus  method.  The 
parts  are  brought  together  and  the  sutures  placed  as 
in  Fig.  211,  beginning  the  first  deeply  and  nearly  to  the 
mucous  membrane,  just  below  the  prolabial  margin, 


171 


which  controls  the  bleeding.  One  or  two  of  the  sutures 
should  be  made  deeply  to  overcome  the  tension  of  the 
parts  as  far  as  possible. 

A  few  fine  stitches  are  taken  in  the  vermilion  part 
of  the  lip  and  several  in  the  mucous  membrane  to  per- 
mit of  close  apposition  and  to  insure  primary  union. 
Wounds  of  the  lips  heal  very  well,  and  the  defects  occa- 
sioned by  even  extension  operations  which  involve  as 
much  as  one  half  of  the  lip  soon  lose  their  acute  hideous 
appearance. 

Estlander  Method. — Estlander  corrects  a  unilateral  de- 
fect by  excising  the  neoplasm  in  triangular  fashion,  and 


FIG.  212. 


FIG.  213. 


ESTLANDER  METHOD. 


cutting  out  a  triangular  flap  from  the  upper  and  outer 
third  of  the  upper  lip,  leaving,  however,  the  prolabium 
intact,  which  answers  for  the  pedicle  (see  Fig.  212). 

This  triangular  flap  is  rotated  downward,  and  is  su- 
tured into  the  opening  in  the  lower  lip,  as  shown  in 
Fig.  213. 

Where  this  method  can  be  employed  it  does  very  well, 
as  it  overcomes  the  secondary  defect  so  common  with 
most  of  these  operations,  while  a  small  operation  may  be 
undertaken  later  to  correct  the  mouth  formation  if 
necessary. 

Bruns  Method. — Bruns  removes  the  defect  in  quadrilat- 
eral form  when  the  disease  involves  one  half  or  more  of 


172     PLASTIC 


COSMETIC    SUKGEKY 


the  lower  lip,  as  shown  in  Fig.  214.  He  encircles  the 
mouth  by  two  curved  incisions  to.  aid  in  mobilizing  the 
edges  of  the  wound,  which  he  sutures,  as  shown  in  Fig. 


FIG.  214. 


BBDNS  METHOD. 


FIG.  215. 


215,  leaving  two  crescentic  wounds  at  either  side  of  the 
mouth,  which  are  allowed  to  heal  by  granulation. 

Buck  Method. — Buck  has  corrected  a  unilateral  defect 
by  employing  the  wedge-shaped  incision,  as  shown  by  B, 
C,  D  in  Fig.  216.  After  removing  the  triangular  infected 
area  he  detaches  the  remaining  half  of  the  lip  from  the 
jaw  as  low  down  as  its  inferior  border  and  as  far  back 


BUCK  METHOD. 


as  the  last  molar  tooth.  A  division  of  the  buccal  mucous 
membrane  along  the  same  line  more  readily  permits  of 
sliding  the  remains  of  the  lip  over  to  meet  the  raw  sur- 
face opposite, 


CHETLOPLASTY 


173 


If  the  latter  was  not  possible  he  obtained  additional 
tissue  by  making  a  transverse  incision  from  the  angle  of 
the  mouth  across  the  cheek  to  the  point  A,  or  within  a 
fingers  breadth  of  the  muscle.  A  second  incision  is  made 
downward  from  A  and  a  little  forward  to  the  point  E. 
This  quadrilateral  flap  thus  formed,  with  its  upper  half 
lined  with  mucous  membrane  is  dissected  up  from  the  jaw 
except  at  its  lower  extremity.  It  is  glided  forward  edge- 
wise to  meet  the  remaining  half  of  the  lip,  where  it  is 
sutured  into  place,  as  shown  in  Fig.  217. 

To  cover  the  triangular  raw  space  occasioned  by  the 
sliding  forward  of  the  flap  A,  B,  C,  E,  another  transverse 
incision  is  made  through  the  skin  continuing  the  line  A,  D, 
Fig.  217,  to  the  extent  of  one  inch.  The  skin  is  then 
dissected  up  as  far  as  this  incision  will  allow  and  is 
stretched  forward  until  the  edge  meets  the  outer  skin 
margin  of  the  quadrilateral  flap,  to  which  it  is  sutured. 
A  later  operation  for  the  restoration  of  the  mouth  has 
to  be  made. 

Dieffenbaeh  Method. — Dieffenbach's  method  is  very  simi- 
lar to  the  above,  but  is  applicable  only  to  cases  where  the 


FIG.  218. 


DlEFFENBACH    METHOD. 


FIG.  219. 


entire  lower  lip  is  involved  and  is  extirpated  (see  Fig. 
218).  The  wound  is  sutured  as  in  Fig.  219.  The  second- 
ary wounds  are  either  sutured  as  in  Buck's  method  or 
they  are  covered  immediately  by  Thiersch  grafts  (au- 
thor's method). 


174     PLASTIC    AND    COSMETIC    SURGERY 

Dieffenbacli  allowed  these  secondary  wounds  to  heal 
by  granulation. 

Jasche  Method. — Jasche's  method  is  to  be  preferred  to 
that  of  the  foregoing  author.  After  a  cuneiform  excision 


FIG.  220. 


JASCHE  METHOD. 


FIG.  221. 


of  the  defect  he  adds  two  curved  incisions  extending 
downward  at  either  side  to  insure  mobility  of  the  parts, 
as  shown  in  Fig.  220. 

In  bringing  the  wound  together,  as  shown  in  Fig.  221, 
he  overcomes  the  large  secondary  defects  of  the  operation 
last  considered  by  suturing  the  skin  margins. 

Trendelenburg  Method. — Trendelenburg  has  modified  the 
method  of  Jasche  by  shortening  the  curve  of  the  cheek 


Fia.  222.  FIG.  223. 

TRENDELENBURG  METHOD. 

incisions    so    that   their   outer    borders    were   made   to 
lie   anterior  to   the   facial   artery    (see   Fig.   222),   the 


CHEILOPLASTY 


175 


parts    being   approximated    and   sutured,    as    shown    in 
Fig.  223. 

To  obtain  sufficient  mucous  membrane  to  cover  the 
superior  margin  of  the  two  flaps  when  brought  together 
he  made  the  cheek  incision  only  down  to  the  mucosa, 
dissected  up  the  latter  a  short  distance  from  the  upper 
part  of  the  cheek,  and  divided  it  about  one  half  centimetre 
above  the  line  of  the  external  incision.  This  flap  of  mu- 
cous membrane  on  either  side  was  used  to  line  the  lip 
in  place  of  the  prolabium. 


FIG.  224. 


BRUNS  METHOD. 


FIG.  225. 


Brims  Method. — Bruns  excises  the  defect  when  not  in- 
volving the  whole  lip  in  quadrilateral  form,  and  takes  up 
a  flap  from  the  anterior  region  of  the  chin  to  cover  it, 
as  shown  in  Fig.  224. 


FIG.  226.  FIG.  227. 

BRUNS  BILATERAL  METHOD. 

This  flap  is  rotated  upward  into  the  wound  made,  and 
is  sutured  in  place,  as  shown  in  Fig.  225.  The  secondary 
wound  is  brought  together  by  suture. 

In  cases  where  the  entire  lip  is  removed  he  cuts  two 


176     PLASTIC   AND    COSMETIC    SURGERY 

square  flaps  from  the  upper  anterior  region  of  the  cheeks 
extending  as  far  upward  as  the  alae  of  the  nose  (see 
Fig.  226). 

He  rotates  these  flaps  into  the  open  wounds  and  su- 
tures them  into  place,  as  shown  in  Fig.  227. 

The  border  of  the  lip  is  lined  with  the  mucous  mem- 
brane of  the  cheek  flaps  then  brought  down.  If  the  latter 
has  become  too  stretched  longitudinally,  he  relieves  it  at 
its  base  by  transverse  incisions. 

Buchanan  Method. — Buchanan's  method  consists  of  re- 
moving the  diseased  area  by  an  elliptical  incision  A,  B,  A. 
A  second  oblique  incision  B,  C,  and  a  third  of  the  same 
obliquity  B,  C,  is  made  downward  and  outward  upon  the 
anterior  chin.  From  the  points  C,  C,  two  curved  in- 
cisions parallel  to  the  upper  incision  A,  B,  A,  and  equal 
to  their  lengths,  are  made  to  the  points  D,  D,  as  shown 
in  Fig.  228. 

The  latter  incisions  provide  two  flaps,  as  shown  in 
Fig.  229.  They  are  dissected  off  from  their  attachment 
to  the  lower  jaw  and  raised  upward  so  that  their  upper 


FIG.  228. 


FIG.  229. 
BUCHANAN  METHOD. 


FIG.  230. 


line  B  is  raised  on  a  level  with  the  former  margin  of 
the  lip  A,  A. 

The  oblique  margins  C,  B,  C  are  thus  brought  together 
vertically  and  sutured  in  the  median  line.  The  mucous 
membrane  is  brought  from  within  outward  and  stitched 
to  the  skin  margin. 

The  operation  leaves  two  triangular  wounds,  which 


177 


are  to  be  healed  by  granulation.  The  result  of  the  rota- 
tion and  apposition  of  the  flaps  is  shown  in  Fig.  230. 

Syme  Method. — Syme  removes  the  affected  area  in  tri- 
angular fashion,  and  from  the  apex  of  the  wounds  carries 
two  curved  and  sweeping  incisions  downward  from  the 
anterior  chin  and  beneath,  terminating  at  the  angles  of 
the  jaw  (see  Fig.  231). 

These  two  large  flaps  are  dissected  from  their  attach- 
ment to  the  jaw  and  are  slid  upward  until  the  sides  of  the 


FIG.  231. 


SYME  METHOD. 


FIG.  232. 


triangular  wound  are  raised  to  a  horizontal  line  corre- 
sponding to  the  superior  border  of  the  lower  lip,  when 
the  flaps  are  sutured  vertically  upon  the  anterior  chin 
and  to  the  triangular  island  of  undisturbed  tissue  under- 
neath the  chin,  as  shown  in  Fig.  232. 

The  advantage  of  this  operation  is  that  no  secondary 
wounds  are  left  to  granulate,  the  whole  healing  by  pri- 
mary union. 

Blasius  Method. — The  method  of  Blasius  is  very  similar 
to  the  foregoing,  except  that  this  author  does  not  carry 
his  two  curved  incisions  as  far  downward  and  backward 
(see  Fig.  233). 

The  two  semilunar  flaps  are  made  from  the  tissue  of 

13 


178     PLASTIC    AND    COSMETIC    SURGERY 

the  anterior  chin  and  slid  upward,  and  sutured  in  the 
median  line  and  to  the  intermedian  spur  of  undisturbed 
tissue,  as  in  Fig.  234. 


FIG.  233. 


BLASIUS  METHOD. 


FIG.  234. 


Biirow  Method. — Biirow,  who  favors  the  excisions  of  two 
triangles  of  healthy  tissue  in  restoring  an  entire  loss  of 
the  lower  lip,  proceeds  by  ablating  the  diseased  area  in 
triangular  form.  From  the  angles  of  the  mouth  he  cuts 
two  transverse  incisions,  upon  which  he  outlines  two  tri- 
angles, as  in  Fig.  235. 

The  tissue  included  in  these  triangles  is  removed  en- 
tirely, an  unnecessary  loss  and  one  unwarrantable,  but 
he  saves  the  mucosa  of  these  excised  portions  with  which 
he  lines  the  upper  margin  of  the  newly  formed  lip. 


FIG.  235. 


BUROW  METHOD. 


FIG.  236. 


The  freed  lateral  chin  flaps  he  slides  forward  so  that 
their  oblique  borders  meet  vertically  in  the  median  line, 
where  they  are  sutured. 


CHEILOPLASTY  179 

The  triangular  wounds  in  the  cheeks  are  by  this  slid- 
ing process  obliterated,  and  their  raw  edges  are  sutured 
vertically,  as  shown  in  Fig.  236. 

Von  Langenbeck  Method. — Von  Langenbeck,  contrary  to 
the  double-flap  methods,  uses  only  one  flap,  with  a  lat- 
eral pedicle  from  the  anterior  chin. 

After  a  semilunar  excision  of  the  diseased  area,  he 
cuts  obliquely  downward  upon  the  anterior  chin,  then 
rounds  his  incision  and  continues  it  along,  just  above 
the  margin  of  the  chin,  gradually  cutting  upward  until  its 
extremity  is  obliquely  opposite  to  the  angle  of  the  mouth, 
as  in  Fig.  237. 

The  flap  thus  formed  will  be  seen  to  have  a  pedicle  at 
this  point.  It  is  dissected  away  from  its  mucous  attach- 


FIG.  237.  Fro.  238. 

VON  LANGENBECK  METHOD. 

ment  and  is  rotated  upward,  jumping  it  over  the  trian- 
gular spur,  which  has  also  been  mobilized  by  a  sliding 
dissection. 

The  flap  is  sutured  into  position,  as  shown  in  Fig. 
238.  Unfortunately,  the  flap  does  not  permit  of  lining 
the  raw  margin  of  the  wound  with  mucous  membrane 
turned  outward  from  within,  hence  it  is  best  to  take  suf- 
ficient of  the  mucous  membrane  from  the  cheeks  to  accom- 
plish this,  or  the  vermilion  border  of  the  upper  lip  may  be 
carefully  cut  away  from  the  lip  at  its  outer  sections  just 
above  the  prolabial  line,  and  elongated  by  stretching  upon 
the  raw  surface  of  the  under  lip,  to  which  it  is  sutured. 


Morgan  Method. — For  an  extensive  loss  of  the  lower  lip 
Morgan  operates  in  the  following  manner: 

After  a  thorough  elliptical  extirpation  of  the  diseased 
area,  he  makes  a  curved  incision  in  the  tissue  under  the 


FIG.  239. 


FIG.  240. 


MORGAN  METHOD. 


chin,  conforming  in  its  curvature  to  the  incision  made 
below  the  diseased  area  of  the  lip  (see  Fig.  239).  The 
length  of  this  incision  is  about  twelve  centimeters. 

This  bridging  flap  is  carefully  dissected  up  from  its 
basement  membrane.  Any  infected  glandular  tissue  en- 
countered in  the  meantime  is  removed  thoroughly. 

The  whole  bridge  of  tissue  is  now  crowded  upward, 
until  it  displaces  the  defect  in  the  lip.  It  is  sutured  on 
either  side,  as  shown  in  Fig.  240,  to  hold  it  in  position. 

Several  sutures  are  introduced  along  its  inferior  mar- 
gin, to  tie  it  to  the  tissue  of  the  anterior  jaw  border  and 
to  prevent  its  sliding  downward. 

Strips  of  borated  gauze  are  laid  into  the  fold  between 
the  raw  surface  of  the  flap  and  the  jaw. 

The  secondary  elliptical  submental  wound  is  drawn 
together  by  suture  as  far  as  possible ;  the  remaining  raw 
surface  is  either  allowed  to  heal  by  granulation  or  is 
covered  immediately  with  Thiersch  grafts  (Wolfler,  Reg- 
nier). 

The  objection  experienced  with  the  method  just  con- 
sidered is  found  in  the  difficulty  with  which  the  bridge 


OHEILOPLASTY  181 

flap  is  carried  upward  over  the  prominence  of  the  jaw- 
bone. It  is  very  essential,  therefore,  to  give  as  much 
freeness  to  this  flap  as  possible,  a  fact  necessitating  con- 
siderable injury  to  the  flap  by  handling  and  cutting,  al- 
though the  result  of  the  operation,  if  carefully  done,  is 
excellent ;  the  lip,  owing  to  its  solid  form  and  undisturbed 
mucous  membrane,  does  not  contract  as  readily  as  with 
the  average  lip  operation,  and  consequent  ectropion  is 
overcome  to  a  great  extent. 

Zeis  Method. — To  overcome  the  difficulty  of  sliding  this 
bridgelike  flap,  Zeis  advocates  ablating  the  diseased  area 
in  quadrilateral  form  and  forming  the  lip  of  unbroken 
tissue  by  making  the  flap  two-tailed  (see  Fig.  241),  each 
flap  meeting  anteriorly  in  a  bridge  of  tissue  sufficiently 
wide  to  permit  of  the  formation  of  the  required  lower  lip 


FIG.  241.  FIG.  242. 

ZEIS  METHOD. 

and  extending  obliquely  downward  and  backward  upon 
the  submental  surface,  having  their  pedicles  as  far  back 
and  upon  the  neck  as  is  necessary  to  allow  the  two-tailed 
flap  to  move  forward  into  position. 

The  parts  are  slid  into  position  and  sutured,  as  shown 
in  Fig.  242. 

Unfortunately  the  tissue  of  the  neck  is  not  very  thick, 
nor  is  it  well  nourished,  factors  that  do  not  make  it  very 
satisfactory  for  cheiloplastic  purposes. 

Delpech  Method. — Delpech  has  utilized  the  skin  of  the 
anterior  neck  region  in  the  following  manner :  He  ablates 
the  extensive  diseased  area,  as  shown  in  Fig.  243,  and 
dissects  up  an  inverted  triangular  pedunculated  flap  of 


182     PLASTIC    AND    COSMETIC    SURGEKY 


skin  from  the  hyoidean  region  of  the  neck,  having  its  raw 
surfaces  brought  face  to  face  at  its  distal  extremity  suffi- 
ciently to  line  the  newly  formed  lip  with  skin  which  even- 
tually would  take  on  the  function  of  mucous  membrane. 


FIG. 


FIG.  244. 


DELPECH  METHOD. 


The  whole  flap  was  now  rotated  upward  on  an  arc  of 
180°  and  sutured  into  the  labial  defect,  as  shown  in 
Fig.  244. 

The  large  wound  of  the  neck  was  readily  drawn  to- 
gether by  suture,  leaving  only  a  small  triangular  space  to 
heal  by  granulation. 

As  has  been  mentioned,  the  skin  of  the  neck  is  not 
adaptable  for  this  purpose,  not  only  because  of  its  poor 
nourishment  and  extreme  thinness,  but  because  a  flap 
made  therefrom  is  devoid  of  muscular  structure,  con- 
tracts easily,  and  is  devoid  of  a  mucous-membrane  pro- 
labium,  the  greatest  objection  being  in  the  resultant  con- 
traction of  the  lip  so  formed,  which  usually  constitutes 
so  high  a  degree  of  ectropion  of  the  lip  as  to  allow  the 
saliva  to  escape  from  the  mouth. 

Apart  from  the  ingenuity  of  the  method  it  has  no 
practical  value,  for  the  reasons  given. 

Larger  Method. — Larger  restores  two  thirds  of  the  lower 
lip  after  the  ablation  of  an  epithelioma,  as  follows : 

1.  An  incision  is  made  from  the  union  of  the  left  third 


CHE1LOPLASTY  183 

with  the  right  two  thirds  of  the  upper  lip,  directed  toward 
the  alae  of  the  nose  and  including  the  entire  thickness 
of  the  lip,  the  cul-de-sac,  and  the  buccal  mucous  mem- 
brane. 

2.  A  second  incision  is  made  from  the  upper  extremity 
of  the  first  incision  downward  from  the  naso-labial  fold 
to  a  point  on  the  cheek  a  little  below  and  to  the  left  of 
the  left  labial  commissure.  The  flap  being  turned  down, 
is  sutured  by  its  three  edges  to  the  lip  of  the  quadrangu- 
lar breach,  after  the  lower  edges  of  the  flap  has  been 
freshened ;  this  border  being  formed  by  the  mucous  mem- 
brane of  the  upper  lip,  the  membrane  is  destroyed  in 
order  to  permit  of  the  edge  being  sutured  to  the  hori- 
zontal branch  of  the  loss  of  substance.  The  upper  lip 
is  then  sutured  vertically  to  the  cheek. 

Gurnard  Method. — Guinard  modifies  the  above  method 
by  making  the  operation  bilateral  and  symmetrical  in- 
stead of  unilateral,  thus  giving  marked  facial  symmetry ; 
the  mucous  membrane  forming  the  free  edge  of  the  upper 
lip,  instead  of  being  destroyed,  is  dissected,  turned  over, 
and  is  sutured  in  a  groove  in  front  of  the  maxillary  in 
such  a  way  as  to  reconstitute  the  buccal  vestibule;  the 
mucous  membrane  of  the  deep  surface  of  the  lip  is  su- 
tured to  the  skin  by  eversion  in  order  to  form  a  new 
mucous  border. 

With  the  above  modification  of  the  Larger  method  a 
considerable  loss  of  substance  can  be  restored,  the  new 
lip  being  constructed  of  normal  tissue  of  the  lip  lined 
with  mucous  membrane  retaining  the  saliva.  Naturally 
the  secondary  deformity,  while  great,  is  one  that  only 
changes  the  physiognomy,  leaving  the  face  symmetrical 
with  slight  cicatrices.  . 

Berger  Method. — Berger  advocates  replacing  a  large 
loss  of  skin  from  the  lower  lip,  the  result  of  burns,  lupus, 
or  syphilitic  ulceration,  by  employing  a  pedunculated 
flap  made  from  the  arm. 

The  free  borders  of  the  flap  are  sutured  into  the 


184      PLASTIC    AND    COSMETIC    SUKGEKY 

defect  and  the  arm  is  bandaged  to  the  head  in  the  proper 
position.  The  pedicle  on  the  arm  is  not  divided  until  the 
flap  has  become  thoroughly  reunited,  which  is  at  the  end 
of  eight  to  twelve  days. 

He  dissects  up  and  divides  the  free  border  of  the 
mucosa  until  it  is  free  from  its  attachments  to  fibers 
of  the  orbicularis  muscle.  This  he  utilizes  in  lining 
the  flap. 

The  flap  taken  from  the  arm  may  be  made  large 
enough  to  cover  the  entire  anterior  aspect  of  the  chin. 

When  the  mucosa  has  been  destroyed  partially  he 
advises  releasing  whatever  remains  of  the  mucous  mem- 
brane, either  as  it  may  be,  and  loosening  it  so  as  to 
inclose  the  buccal  orifice.  He  slides  a  flap  taken  from 
the  subhyoid  region  to  reconstruct  the  lip  over  this,  or 
resorts  to  the  Italian  method  just  described. 

LABIAL  DEFICIENCY 

Where  the  lip  structure  has  become  flattened  and 
thinned  as  a  result  of  tension  following  the  exsection 
of  a  part  of  the  lip,  as  in  harelip,  or  the  ablation  of 
malignant  growths,  operations  may  be  undertaken  to 
give  the  tissue  a  better  cosmetic  appearance. 

Estlander's  operation,  described  on  page  171,  gives, 
perhaps,  the  best  results  in  these  cases,  but  the  objec- 
tion to  this  procedure  to  make  up  the  deficiency  in  the 
other,  and  often  necessitating  a  later  stomatoplasty  to 
overcome  the  oval  shortening  occasioned  by  the  rear- 
rangement of  the  prolabium.  This,  of  course,  is  a  mat- 
ter of  little  consequence  where  the  primary  fault  is  due 
to  the  ulcerative  inroads  of  syphilis  or  the  cicatricial 
contraction  following  burns.  At  any  rate,  the  triangular 
flap  implantation  method  is  to  be  preferred  to  any  other 
cutting  procedure. 

In  simple  cases  where  a  triangular  ablation  has 
caused  the  flattening  the  defect  can  be  overcome  to  a 


CHE1LOPLASTY  185 

great  extent  by  employing  the  subcutaneous  method  of 
Gersuny. 

Author's  Method. — The  author  recommends  a  subcuta- 
neous division  of  the  scar  line  in  cases  permitting  such 
procedure  prior  to  the  injection  of  the  tissues.  This  is 
accomplished  with  a  fine  tenotome,  which  requires  only 
the  making  of  a  small  opening  in  the  skin  through  which 
the  filling  can  be  introduced.  A  single  suture  may  be 
made  through  the  lips  of  the  wound,  which  is  tied  imme- 
diately after  the  filling  has  been  introduced  to  avoid  the 
displacement  or  pressing  out  of  the  injected  mass  at 
this  point,  which  is  sure  to  result  if  the  suture  be  intro- 
duced after  the  injection. 

A  secondary  filling  may  be  found  to  be  necessary 
subsequently  to  obtain  the  desired  cosmetic  result.  The 
process  of  subcutaneous  filling  is  fully  considered  in 
Chapter  XIV. 

When  the  lower  lip  is  extremely  flattened  by  the  ten- 
sion of  cicatricial  contraction  of  burn  wounds  of  the 
mental  region  with  more  or  less  ectropion  of  the  lip. 

Teale  Method. — Teale  advocates  the  following  method: 

Two  cheek  flaps  are  formed  by  making  a  curved  out- 
ward and  upward  incision  upon  either  cheek,  terminat- 


FIG.  245.  FIG.  246. 

TEALE  METHOD. 

ing  at  the  second  molar  tooth  of  the  upper  jaw  and  corre- 
sponding to  the  lines  A,  A,  in  Fig.  245.  These  terminate 
anteriorly  in  two  vertical  incisions  about  three  quarters 
of  an  inch  long,  made  through  the  entire  lip  structure 
down  to  the  bone  on  a  line  with  the  canine  teeth. 


186      PLASTIC    AND    COSMETIC    SURGERY 

The  upper  extremity  of  the  two  vertical  incisions  are 
united  with  a  horizontal  incision  through  the  thinned- 
out  or  everted  prolabium. 

The  two  cheek  flaps  are  dissected  off  from  the  bone, 
the  mucous  membrane  uniting  them  to  the  alocoli  being 
freely  divided. 

A  base  surface  is  made  along  the  alocolar  border  of 
the  median  portion  of  the  lip  between  the  upper  extrem- 
ities of  the  two  vertical  incisions  first  made. 

The  flaps  A,  A  are  then  brought  together  so  that  their 
vertical  margins  meet  at  the  median  line,  where  they 
are  sutured.  A  few  fine  sutures  are  taken  through  the 
vermilion  border. 

A  secondary  wound,  C,  C,  at  either  side  is  thus  occa- 
sioned (Fig.  246),  which  can  at  once  be  covered  with 
Thiersch  grafts  or  is  allowed  to  heal  by  granulation. 

Where  the  deficiency  is  due  to  cicatricial  contractions 
of  the  submental  tissue  the  latter  must  be  divided  hori- 
zontally from  one  healthy  border  to  the  other,  the  parts 
freed  well  from  all  subcutaneous  adhesions  in  the  cellu- 
lar structure.  The  head  should  be  forcibly  raised  and  a 
flap  of  skin  be  placed  into  the  elliptical  wound  thus 
formed  either  by  the  rotation  of  a  pedunculated  neck 
or  thorax  skin  flap  or  the  implantation  of  Wolfler  or 
Thiersch  grafts. 

Carefully  keeping  the  head  in  an  extended  position 
during  the  healing  in  of  these  grafts  will  overcome  the 
primary  defect,  unless  the  lip  itself,  too,  has  become 
tied  down,  when  the  bridge  flap  method  of  Morgan  or 
Zeis  can  be  undertaken  in  conjunction  with  the  skin- 
grafting  method  to  correct  the  fault. 

LABIAL  ECTROPION 

Eversion  of  the  lip  may  be  due  to  cicatricial  contrac- 
tion of  ulcerative  wounds,  burns,  and  traumatisms  of 
the  skin,  or  it  may  be  hereditary.  In  the  latter  case  the 


CHEILOPLASTY  187 

entire  lip  structure  is  more  or  less  overdeveloped,  as  in 
the  negro,  especially  in  the  lower  lip,  so  that  the  thick- 
ened lip  droops  forward  and  downward.  This  condition 
is  termed  macrocheila. 

Ectropion  of  the  lower  lip  is  more  common  than  in 
the  upper  lip.  The  defect  may  be  slight  and  only  of 
cosmetic  importance  or  it  may  be  so  extensive  as  to  per- 
mit an  overflow  of  the  saliva  from  the  mouth. 

When  the  cause  of  deformity  is  due  to  a  cicatrix  of 
the  skin,  as  often  met  with  in  the  lower  lip,  a  flap  should 
be  neatly  raised  by  a  V  incision,  as  with  ectropium  of 
the  lower  lid  on  page  104,  and  the  wound  sewed  in  the 
Y  form  (Dieffenbach). 

In  cases  of  severer  form  the  cicatrix  is  removed  by 
an  elliptical  incision,  the  lip  returned  to  its  natural  posi- 
tion, and  a  pedunculated  flap  of  skin  is  taken  up  from 
the  chin  or  the  cheek  which  is  rotated  into  the  wound, 
or  a  skin  graft  is  implanted  into  the  area  by  the  Wolfler 
method  and  sutured  to  the  free  margins  of  the  skin,  or 
the  Thiersch  method  may  be  employed. 

In  hereditary  cases  of  mild  form  or  partial  ectropion 
the  author  advocates  making  two  vertical  incisions  in 


\ 


FIG.  247.  FIG.  248. 

AUTHOR'S  METHOD. 

the  mucous  membrane,  half  an  inch  long,  one  half  inch 
distant  from  the  median  line  of  the  lip,  and  suturing 
them  horizontally,  as  shown  in  Figs.  247  and  248. 

In  some  cases  the  ectropion,  whether  partial  or  more 
or  less  general,  is  caused  by  protrusion  of  the  teeth 
either  of  the  upper  or  lower  jaw ;  more  commonly  of  the 
alveolar  structure  of  the  superior  maxillary  bone.  In 
such  cases  a  cosmetic  operation  on  the  mucosa  will  do 


188      PLASTIC    AND    COSMETIC    SUKGERY 

little  to  restore  the  deformity.  Such  cases  should  be 
corrected  primarily  by  a  surgeon  dentist,  the  teeth  being 
forced  back  into  place  by  proper  metal  springs  or  splints 
—a  tedious  process  requiring  from  six  months  to  two 
years'  time. 

If,  after  the  teeth  have  been  brought  back  to  the  nor- 
mal bite,  the  lip  still  shows  an  abnormal  contour,  the 
surgeon  may  restore  this  by  several  small  incisions  in 
the  mucosa,  as  above  advised,  at  the  various  protruding 
points  of  the  lip. 

When  the  simple  vertical-line  incisions  sutured  hori- 
zontally will  not  accomplish  the  result,  the  excision  of 
small  triangles  or  elliptical  pieces  of  the  mucosa  may 
be  made,  bringing  the  distal  edges  of  the  wounds  to- 
gether horizontally  with  silk  sutures,  which  are  found 
best  for  suturing  wounds  about  the  buccal  cavity. 

The  same  methods  as  above  given  apply  to  the  cor- 
rection of  upper-lip  deformities. 

Where  the  fault  is  too  great  to  be  overcome  by  this 
method,  the  author  advocates  removing  an  elliptical  or 


FIG.  249.  FIG.  250. 

AUTHOR'S  METHOD. 

diamond-shaped  piece  of  the  lip  from  the  inner  surface 
or  mucosa,  the  whole  length  of  the  lip  and  wide  enough 
to  correct  the  fault,  as  shown  in  Fig.  249,  and  bringing 
together  the  margins  by  an  interrupted  suture,  as  in 
Fig.  250.  This  is  the  most  satisfactory  method  to  re- 


CHEILOPLASTY  189 

store  either  the  upper  or  lower  lip  to  normal  position. 
The  resulting  cicatrix  of  the  mucous  membrane  offers 
no  objection  whatever,  and  soon  becomes  obliterated. 

If  the  operator  feels  justified  to  remove  a  triangular 
piece,  with  its  base  upward,  in  case  of  the  lower  lip,  and 
vice  versa,  from  the  whole  thickness  of  the  lip  he  can 
do  so,  but  the  operation  has  the  objection  of  leaving  a 
noticeable  vertical  scar  in  the  skin  and  a  notch  in  the 
vermilion  border. 

The  former  can  of  course  be  materially  hidden  by 
the  mustache  or  beard  in  man. 

LABIAL  ENTROPION 

While  labial  inversion  is  in  most  cases  caused  by  the 
removal  of  tissue  from  the  inner  or  whole  lip  structure 
due  to  disease  or  other  causes,  it  may  nevertheless  be 
met  with  in  hereditary  instances.  The  condition  is 
termed  microcheila. 

It  is  more  common  in  the  upper  lip,  perhaps  because 
of  the  frequency  of  harelip  corrections  undertaken  with 
that  part  of  the  mouth,  but  it  may  involve  both  lips  or 
be  partial  in  one  or  both  lips;  in  the  latter  case  often 
the  result  of  the  habit  of  talking,  chewing,  or  laughing 
with  one  side  of  the  mouth,  in  which  the  active  side  is 
the  normal  and  the  passive  side  the  one  showing  a  lack 
of  development. 

In  the  latter  case  daily  facial  gymnastics  should  be 
advised,  and  such  teeth  as  need  attention  to  permit  of 
the  use  of  the  side  favored  should  be  restored  to  use- 
fulness— the  loss  or  uselessness  of  teeth  in  the  earlier 
days  of  puberty  often  causing  the  deformity.  The  cor- 
rection of  such  defect  has  in  view  to  widen  the  lip  struc- 
ture, and  the  best  method  to  follow  is  the  suturing  of 
one  or  more  horizontal  incisions  in  a  vertical  direction, 
these  incisions  depending  in  number  upon  the  extent 
of  the  lack  of  tissue,  whether  total  or  partial.  This,  of 


190     PLASTIC   AND    COSMETIC    SURGERY 

course,  overcomes  only  the  rolling  in  of  the  vermilion 
border,  and  does  not  in  cases  of  the  extensive  variety 
overcome  the  deformity.  In  such  cases  an  incision  is 
made  through  and  along  the  entire  nmcosa  half  an  inch 
below  the  vermilion  border.  The  incision  should  be  made 
deep  enough  to  permit  of  free  movement  of  the  upper 
section  of  the  lip,  which  is  drawn  up  by  an  assistant, 
while  a  flap  of  mucosa,  either  pedunculated  or  free  and 
taken  from  the  inner  side  of  the  cheek  in  the  near  vicin- 
ity to  the  lip,  is  sutured  into  the  opening  thus  made  by 
traction. 

If  a  pedunculated  flap  is  employed,  it  should  be 
cut  in  such  a  way  that  the  twisting  or  rotation  of  its 
pedicle  will  not  be  too  abrupt,  and  thus  cause  gan- 
grene. 

The  secondary  wound  is  sutured  with  silk  and  heals 
quite  readily  under  proper  hygienic  care  (see  matter  on 
mucous-membrane  grafting,  page  101). 

If,  for  traumatic  reasons,  a  more  extensive  opera- 
tion involving  the  whole  lip  structure  is  indicated,  one 
of  the  harelip  operations  heretofore  given  will  answer 

the  best  purpose. 

• 

VERMILION  DEFICIENCY 

The  cosmetic  surgeon  is  often  called  upon  to  correct 
the  vermilion  borders  of  the  lips,  the  usual  fault  being 
a  lack  of  sufficient  of  the  delicate  membrane  to  give  an 
artistic  appearance  or  form  to  the  mouth,  and  in  some 
rare  cases  the  absence  of  the  so-called  "  Cupid's  Bow  " 
of  the  upper  lip. 

Surgical  means  are  of  little  avail  to  correct  or  beau- 
tify such  fault,  and  the  cosmetic  operator  must  resort 
to  other  means.  The  only  practicable  method  at  hand 
is  the  careful  tattooing  of  the  skin  with  rose  pigment 
introduced  into  the  skin,  preferably  with  an  electric  in- 
strument made  for  that  purpose.  The  hand-tattooing 


CHEILOPLASTY  101 

method  is  slow,  irregular  at  best,  and  much  more  painful 
because  of  this. 

The  part  to  be  tattooed  is  first  outlined  and  then  tat- 
tooed in  linear  fashion  parallel  to  the  vermilion  border 
presenting,  working  upward  to  the  peripheral  line.  The 
color  applied  should  be  pale  rose  at  the  first  sitting,  to 
be  gone  over  after  healing  has  taken  place,  and  repeated 
even  thereafter  until  the  desired  shade  has  been  at- 
tained. 

The  method  and  instruments  involved  in  the  above 
and  the  tattooing  of  scar  tissue  is  fully  described  in  a 
later  chapter. 


CHAPTER   XII 

STOMATOPLASTY 
(Surgery  of  the  Mouth) 

THIS  branch  of  surgery  has  to  do  with  the  plastic 
restoration  of  the  oral  orifice.  Operations  of  this  kind 
are  required  to  enlarge  a  contracted  mouth,  termed 
microstoma,  whether  the  same  be  due  to  congenital  ori- 
gin or  to  cicatricial  contraction  after  operative  interfer- 
ence about  this  origin. 

Stomatoplasty  may  also  be  needed  to  rebuild  an  ab- 
normally enlarged  mouth,  termed  macrostoma,  which 
has  already  been  described  on  page  149. 

THE   CORRECTION   OF  MACROSTOMA 

The  operative  methods  to  correct  the  latter  need  lit- 
tle mention,  since  there  is  usually  sufficient  tissue  pres- 
ent from  which  the  orifice  can  be  properly  formed. 

The  simplest  method  is  to  excise  the  borders  of  the 
enlarged  mouth  or  buccal  clefts,  whether  unilateral  or 
bilateral,  and  to  bring  the  raw  edges  together  by  su- 
ture. These  sutures  should  be  made  nearly  through  the 
muscular  walls  of  the  cheek  and  at  sufficient  distance 
from  the  edges  of  the  wounds  to  avoid  tearing  through. 

When  the  cleft  is  of  sufficient  length  to  warrant  ten- 
sion sutures,  they  may  be  employed,  alternating  with 
superficial  sutures  to  neatly  coapt  the  skin  surfaces. 

The  mucous  membrane  should  also  be  sutured  with 
fine  silk  to  insure  a  perfect  closure  of  the  parts,  and  to 
avoid,  as  far  as  possible,  intra-oral  infection. 

192 


STOMATOPLASTY 


193 


When  possible  the  vermilion  borders  of  the  lips 
should  be  neatly  brought  out  to  the  angles  of  the  mouth, 
where  they  should  be  sutured  one  to  the  other  somewhat 
diagonally.  This  will  tend  to  give  the  angles  a  normal 
appearance  and  shape. 

Dieffenbach-Von  Langenbeck  Method. — It  is  not  unusual 
after  the  extirpation  of  a  malignant  growth  that  a 
greater  part  of  the  prolabium  has  been  sacrificed  in 
either  of  the  lips.  In  this  event  the  vermilion  border 
must  be  carefully  and  neatly  trimmed  away  from  the 
healthy  lip,  leaving  a  median  attachment  (see  Fig. 
251). 

The  two  strips  of  prolabium  will  be  found  to  stretch 
easily.  They  are  utilized  to  line  the  entire  denuded  raw 


FIG.  251.  FIG.  252. 

DlEFFENBACH-VoN  LANGENBECK  METHOD. 

surface  and  are  held  in  position  by  a  number  of  fine  silk 
sutures,  as  shown  in  Fig.  252. 

Accessory  mobilizing  incisions,  as  shown  in  the  above 
figures,  may  be  necessary  to  contract  the  oral  orifice 
sufficiently  to  permit  of  such  a  prolabial  grafting,  espe- 
cially where  a  greater  part  of  the  vermilion  border  has 
been  destroyed.  These  extra  incisions  are  not  necessary 
when  only  a  small  part  of  the  latter  is  lost;  a  partial 
unilateral  dissection  in  that  case  would  suffice  to  restore 
the  part. 

This  prolabial  lining  of  the  mouth  gives  it  a  puckered 
and  contracted  appearance  for  a  time  only,  because  the 
14 


194     PLASTIC   AND    COSMETIC    SURGERY 

parts  soon  stretch,  while  oral  gymnastics  will  help  much 
in  restoring  its  size  and. usefulness. 

The  objection  to  the  above  method  is  the  danger  of 
partial  or  total  gangrene  of  that  part  of  the  prolabium 
which  has  been  dissected  up  and  stitched  to  line  the 
mouth  as  a  result  of  lack  of  nutrition  or  to  the  bruising 
or  rough  handling  of  the  delicate  strips  during  the  oper- 
ation. 

Tripier  Method. — Tripier  refashions  the  prolabium  of 
the  mouth  by  means  of  a  mucous  strip  taken  from  the 
inner  surface  of  the  lip.  This  strip  is  left  attached  at 
both  ends,  forming  a  bridge  flap  of  mucous  membrane, 
the  pedicles  of  the  ends  giving  nourishment  to  the  whole. 
The  bridging  strip  is  slipped  into  place  and  is  sutured 
to  the  outer  skin  by  its  superior  border,  so  as  to  restore 
the  normal  appearance  and  thickness  of  the  lip. 

Antisepsis  must  be  carried  out  scrupulously  and  a 
strip  of  iodoform  gauze  be  placed  between  the  lips  oper- 
ated upon  and  the  gum.  In  forty-six  cases  operated 
upon  by  this  method  forty-two  were  successful,  while 
in  two  of  the  unsuccessful  cases  there  was  partial  gan- 
grene of  the  flap. 

Macrostoma  and  Overdevelopment  of  the  Lips. — In  the  cos- 
metic correction  of  macrostoma  there  may  be  an  overde- 
velopment of  one  or  both  lips  as  well  as  the  wide  oral 
fissure.  In  such  cases  the  lip  structures  is  to  be  reduced 
by  the  methods  heretofore  given,  before  shortening  of 
the  mouth  line  is  undertaken,  because  of  the  greater 
freedom  allowed  the  surgeon  to  correct  the  deformity. 

If  possible  the  operation  at  the  oral  angles  above 
referred  to  should  be  avoided  because  of  a  certain 
amount  of  scarring  of  the  skin  at  either  side  of  the 
mouth  and  the  resultant  stiffness  of  the  parts  due  to 
the  surgical  interference;  therefore,  when  practicable, 
or  when  the  deformity  is  of  moderate  extent,  the  angles 
of  the  mouth  should  be  advanced  toward  the  median 
vertical  of  the  lips.  In  such  case  it  is  best  to  do  such 


STOMATOPLASTY  195 

operations  before  any  labial  corrections  are  under- 
taken. 

Author's  Method, — The  method  advised  by  the  author  is 
the  employment  of  the  Dieffenbach  procedure  as  fol- 
lows: 

A  V-shaped  incision,  its  apex  pointing  inward  and  its 
distal  ends  a  half  inch  from  the  prolabial  line,  is  made 
quite  deep  through  the  mucosa  and  muscular  tissue,  as 


FIG.  253.  FIG.  254. 

AUTHOR'S  METHOD. 

shown  in  Fig.  253.  The  part  included  in  the  V  is  now 
drawn  toward  the  median  line  of  the  lip,  causing  the 
wound  to  gape.  The  latter  is  then  sutured  with  deep 
and  superficial  silk  sutures  in  the  form  of  a  Y,  as  shown 
in  Fig.  254.  The  same  operation  is  repeated  at  the  other 
angle  of  the  mouth. 


THE  CORRECTION   OF  MICROSTOMA 

When  the  oral  orifice  has  become  lessened,  as  is  fre- 
quently the  result  of  cicatricial  contraction  following 
ulcerations  or  operative  interference,  but  which  may, 
too,  occur  congenitally,  the  condition  is  termed  micros- 
toma. 

Dieffenbach  Method. — Dieffenbach  advocates  the  follow- 
ing operation  for  the  correction  of  this  abnormality: 

Two  lateral  incisions  are  made  outward  from  the 
mouth  across  the  cheeks  and  through  their  entire  thick- 
ness, extending  in  length  a  little  beyond  the  intended 
angle  of  the  mouth  (see  Fig.  255).  The  mucous  mem- 
brane from  within  is  brought  forward  and  is  sutured 
superiorly  and  inferiorly  to  the  skin  with  fine  silk  su- 
tures. 


196     PLASTIC   AND    COSMETIC    SURGERY 


If  there  be  any  difficulty  experienced  in  accomplish- 
ing this,  owing  to  the  presence  of  cicatricial  thickening 
of  the  parts,  the  latter  must  be  excised  in  gutterlike 


FIG.  255.  FIG.  256. 

DlEFFENBACH  METHOD. 

fashion   (author),  and  the  mucous  membrane  be  freed 
from  its  attachment  until  it  comes  into  place  readily. 
Care  should  be  especially  exercised  in  lining  the  an- 
gles of  the  newly  formed  mouth. 

The  subsequent  contraction  of  the  rima  oris  follow- 
ing the  above  operation  is  prevented  only  by  lining  the 
angle  with  mucous  membrane,  healing  into  place  by  first 
intention. 

Hose  Method. — Rose  advises  sewing  a  small  triangular 
flap  of  mucous  membrane  into  each  angle  to  overcome 
the  contraction. 

Heuter  Method. — Heuter  employs  an  artificial  mouth  of 
hard  rubber  tubing  of  a  size  corresponding  to  the  new 
mouth  made  in  the  form  shown  in  Fig. 
257. 

This   ring  is  forced  into  the  oral 
opening  and  the  patient  is  instructed 
to  wear  it  for  some  weeks  after  the 
operation  or  until  the  tissues  have  be- 
come softened  and  elongated  and  will  no  longer  retain  it. 
Nonoperative   Treatment. — Smaller  operations  about  the 
mucosa  alone  are  of  no  avail  to  correct  this  deformity, 
but  where  the  contraction  of  the  oral  orifice  is  moderate 
and  of  recent  origin,  exercising  the  mouth  and  stretch- 
ing the  angles  forcibly  may  help  to  overcome  the  de- 


FIG.  257. — ARTIFICIAL 
MOUTH.     (Heuter.) 


STOMATOPLASTY  197 

formity  to  a  great  extent.  Smaller  deformities  due  to 
contraction  usually  subside  after  a  time  from  the  normal 
use  of  the  mouth. 

The  hypodermic  injection  of  a  solution  of  thiosani- 
min  or  fibrolysin  (Mendel)  are  of  import  in  cases  where 
an  operation  cannot  be  undertaken.  Their  use  is  more 
fully  described  in  a  later  chapter. 


CHAPTER   XIII 

MELOPLASTY 
(Surgery  of  the  Cheeks) 

THIS  branch  of  surgery  has  to  do  with  the  recon- 
struction or  restoration  of  the  cheek  following  the  ex- 
cision of  scars  or  the  extirpation  of  malignant  growths. 
The  procedure  is  also  recognized  as  genioplasty. 

SMALL  AND   MEDIUM  DEFECTS 

Where  the  defect  occasioned  by  the  ablation  is  of 
small  extent,  the  free  and  somewhat  undermined  margins 
of  the  wound,  which  should  be  made  in  elliptical  form,  are 
neatly  .brought  together  with  several  retention  sutures 
alternating  with  superficial  sutures  of  fine  twisted  silk. 

If  deeper  structure  than  the  skin  be  involved,  the  dis- 
eased area  should  be  carefully  removed  even  to  the  limi- 
tation of  the  buccal  mucous  membrane,  the  soft  parts 
detached  from  the  mucous  membrane  to  render  them 
mobile,  and  the  wound  brought  together  by  suture. 
Care  must  be  exercised  so  that  the  tension  of  the  suture 
does  not  create  a  new  deformity,  such  as  blepharal 
ectropium,  distortion  of  the  rima  oris  or  the  alae  of  the 
nose.  If  there  is  enough  mucous  membrane  after  the 
excision  of  the  diseased  area,  Oberst  advocates  closing 
the  defect  with  two  pedunculated  flaps  made  each  from 
the  mucous  membrane  of  the  cheek  and  of  the  lip. 

In  cases  where  the  whole  thickness  of  the  cheek  is 
involved  the  cheek  can  be  incised  from  the  angle  of  the 
mouth  as  far  as  the  border  of  the  masseter  muscle  down 


MELOPLASTY 


199 


to  the  adipose  layer.  A  part  of  the  fatty  tissue  is  ex- 
sected  and  pushed  aside,  the  thumb  of  the  operator  be- 
ing introduced  into  the  buccal  cavity  and  pressed  out- 
ward against  the  cheek  to  determine  the  position  and 
extent  of  the  pathological  involvement.  The  diseased 
area  is  cut  out  with  curved  scissors,  going  well  into  the 
healthy  tissues. 

The  wound  is  then  brought  together  by  suture  while 
the  defect  of  the  mucous  membrane  is  tamponed  for  four 
or  five  days,  when  it  can  be  covered  with  Thiersch 
grafts.  The  latter  in  a  short  time  takes  on  the  appear- 
ance of  mucous  membrane  and  overcomes  the  contrac- 
tion of  the  ordinary  sutured  wound  (Edward- Albert). 

Serre  Method. — For  still  larger  defects  Serre  makes  the 
ablation  in  rectangular  form,  as  shown  at  A,  Fig.  258, 


FIG.  258. 


SERHE  METHOD. 


FIG.  259. 


and  forms  a  longer  flap  of  rectangular  form  from  the 
tissue  of  the  cheek  and  neck.  This  flap  he  dissects  off 
from  the  margin  of  the  maxillary  bone  to  give  it  the 
proper  mobility.  The  flap  is  drawn  upward  and  su- 
tured, as  in  Fig.  259. 

There  is  little  retraction  experienced  in  this  method, 
and  answers  well  for  defects  of  medium  extent. 


LARGE   DEFECTS 

In  larger  defects  the  flaps  to  be  utilized  in  overcom- 
ing the  deformity  must  be  taken  from  the  cheek  above 


FIG.  260.  FIG.  261. 

CORRECTION  OF  ANGLE  OF  MOUTH. 

as  well  as  the  anterior  chin,  as  shown  in  Figs.  260  and 
261. 

Another  method  is  to  cut  the  two  flaps  as  in  Fig.  262. 

These  flaps  are  made  of  the  entire  thickness  of  the 
cheek  tissue,  and  are  slid  down  into  position  and  sutured 
or  approximated,  as  in  Fig.  263. 


FIG.  262.  FIG.  263. 

CORRECTION  OF  EXTENSIVE  DEFECT  AT  ANGLE  OF  MOUTH. 

As  a  rule  the  excised  mucous  membrane  subsequently 
prevents  a  free  opening  of  the  mouth  added  to  by  the 
contraction  of  the  flaps  themselves. 

To  overcome  this  a  flap  of  skin  with  its  epidermal 
surface  turned  inward  is  sutured  into  the  defect,  as  will 
be  shown  presently,  or  a  pedunculated  flap  formed  at  the 


MELOPLASTY  201 

wound  surface  before  its  transplantation  into  the  defect 
may  be  covered  with  skin  grafts  (Thiersch). 

Bayer  Method. — Bayer  has  successfully  utilized  a  large 
flap  from  the  mucous  membrane  of  the  palate  and  cov- 
ered it  externally  with  a  flap  of  skin  taken  from  the 
submaxillary  region. 

Kraske  Method. — Kraske  forms  the  flap  to  be  turned 
into  the  defect  of  the  tissue  immediately  surrounding  it, 
as  shown  in  Fig.  264.  This  flap  may  heal  into  position, 


FIG.  264.  FIG.  265. 

KRASKE  METHOD. 

even  though  its  pedicle  is  made  up  only  of  subcutaneous 
tissue,  according  to  Grersuny. 

The  epidermal  surface  of  such  flap  is  made  to  form 
the  inner  or  mucous  surface  of  the  repaired  cheek  (see 
Fig.  265),  while  its  external  surface  and  the  secondary 
wound  are  covered  with  Thiersch  grafts,  at  one  and  the 
same  sitting. 

The  only  difficulty  experienced  in  the  case  with  men 
is  that  the  bearded  surface  of  this  inturned  flap  offers 
considerable  discomfort  to  the  patient,  although  in  the 
majority  of  cases  the  skin  thus  inverted  soon  takes  on 
the  appearance  of  the  mucosa,  the  objectionable  hairs 
falling  out  and  the  hair  follicles  becoming  obliterated. 


202      PLASTIC    AND    COSMETIC    SURGERY 

Israel  Method. — To  overcome  the  above  objection  Israel 
makes  his  flaps  from  the  skin  of  the  side  of  the  neck, 


FIG.  266. 


FIG.  267. 
ISRAEL  METHOD. 


FIG.  268. 


the  flap  being  elongated  and  attached  at  its  upper  end, 
as  in  Fig.  266. 

This  flap  he  turns  upward  into  the  defects  with  its 
epidermal   surface  facing  inward  and   sutures  it  into 


FIG.  269.  FIG.  270. 

BARDENHEUER  METHOD. 


place,  as  shown  in  Fig.  267,  leaving  the  outer  surface 
to  granulate  over  and  thicken  on  the  sutured  margins 


MELOPLASTY 


203 


to  heal  into  place.  This  requires  from  fourteen  to  sev- 
enteen days,  when  the  pedicle  is  severed  and  the  lower 
or  freed  portion  of  the  flap  is  brought  forward.  The 
granulation  of  the  entire  surface  is  scraped  off  and  the 
free  end  of  the  flap  is  turned  over  upon  itself,  as  it 
were,  and  its  margins  sutured  to  the  descended  skin 
margin,  as  in  Fig.  268. 


FIG.  271. 


FIG.  272. 


FIG.  273. 


FIG.  274. 


BARDENHEUER  METHOD. 


Bardenheuer  Method. — Bardenheuer  has  given  this  sub- 
ject a  great  deal  of  attention,  and  advocates  the  use  of 
the  skin  of  the  forehead  for  closing  these  buccal  or  oral 


204 


defects.  The  skin  of  the  forehead  is  without  hair,  is 
well  nourished,  and  has  little  adipose  tissue  underlying 
it,  facts  that  make  it  especially  useful  for  these  opera- 
tions. The  skin  surface  he  turns  into  the  mouth  cavity, 


FIG.  275. 


FIG.  276. 


FIG.  277.  FIG.  278. 

BARDENHEUER  METHOD. 

while  the  outer  or  raw  surface  is  covered  with  a  pedun- 
culated  skin  flap  taken  from  the  region  of  the  intramax- 
illary  region. 

The  secondary  wounds  of  the  forehead  and  below 
the  jaw  should  be  covered  with  Thiersch  grafts  at  the 
same  sitting. 


205 


The  best  cosmetic  results  are  obtained  by  correcting 
the  entire  defect  at  one  sitting,  as  the  subsequent  con- 
traction of  the  flaps  do  not  allow  of  it  in  successive  oper- 
ations. 

The  apposition  of  the  raw  surfaces  of  the  flap  from 
the  forehead  and  that  of  the  cheek  or  chin  greatly  in- 
creases their  vitality  and  overcomes  markedly  the  cica- 
tricial  contraction. 

The  pedicle  of  the  forehead  flap  is  cut  apart  about 
the  fourteenth  day  and  replaced. 

In  the  case  depicted  in  Fig.  269  a  large  portion  of 
the  cheek  and  the  whole  upper  and  a  part  of  the  lower  lip 
had  to  be  removed.  A  large  flap  taken  from  the  fore- 
head that  turned  into  the  defect  (see  Fig.  270),  and  a 
flap  taken  from  the  intramaxillary  region,  were  brought 
over  the  major  and  lower  portion  of  its  raw  and  outer 
surface. 


FIG.  279. 


Fio.  280. 


STAFFEL  METHOD. 


In  Figs.  271,  272,  and  273  the  various  steps  of  the 
same  operation  are  more  fully  shown,  including  the 
placing  of  the  Thiersch  grafts  and  the  replacing  of  the 
pedicle  in  Fig.  274. 

A  still  more  extensive  restoration  of  the  cheek  is 


206      PLASTIC   AND    COSMETIC    SURGERY 

shown  in  Figs.  275,  276,  and  277,  and  the  position  of  the 
skin  grafts  and  replaced  flap  pedicles  in  Fig.  278. 

Staffel  Method. — Staffel  has  also  utilized  pedunculated 
flaps  taken  from  the  forehead  to  correct  defects  of  the 
cheeks  and  mouth. 

His  method  of  procedure  in  an  aggravated  case  re- 
sulting from  mercurial  stomatitis  with  resultant  cica- 
tricial  trismus  is  shown  in  Figs.  279  and  280. 

Two  pedunculated  forehead  flaps  were  employed  in 
the  above  case  as  well  as  two  flaps  each  attached  by  a 
broad  pedicle  from  the  skin  under  the  chin  Tripier  fash- 
ion, and  although  the  patient  thus  operated  upon  was 
only  five  years  of  age,  an  excellent  result  was  obtained. 

EMPLOYMENT   OF  PROTHESES 

When  the  defect  of  the  cheek  due  to  the  removal  of  a 
greater  part  of  its  structure  is  so  large  as  to  frustrate 


FIG.  281. — CHEEK  PROTHESIS,  AFTER  REMOVAL  OF  SARCOMA. 
(British  Medical  Journal.) 


MELOPLASTY 


207 


all  attempts  at  its  correction  we  may  resort  to  the  em- 
ployment of  protheses  made  for  the  purpose. 

In  Fig.  281  a  case  of  Morris  is  shown  following  the 
removal  of  a  myeloid  sarcoma  involving  a  greater  part 


FIG.  282. — PROTHESIS  APPLIED  TO  FACE. 

(British  Medical  Journal.) 

of  the  upper  cheek,  the  eye,  and  the  palate.  The  opera- 
tor had  a  prothesis  constructed  by  Hayman,  which  pro- 
vided not  only  an  artificial  cheek,  but  also  an  eye  and 
the  palate. 

How  excellently  this  has  been  accomplished  is  de- 
picted in  Fig.  282.    This  prothetic  contrivance  not  only 
improved  the  patient's  appearance,  but  also  enabled  him 
to  speak  intelligibly,  which  had  been  impossible,  owing 
to  the  absence  of  a  greater  part  of  the  soft  palate. 
Hayman  describes  what  he  did  as  follows : 
"  I  obtained  a  model  of  the  mouth,  after  which  an 
ordinary  plate  was  made,  then  a  special  obturator  to 
correct  the  palatine  defect.    With  the  obturator  in  posi- 


208      PLASTIC    AND    COSMETIC    SURGERY 

tion  a  model  of  the  remaining  hollow  was  taken,  and 
from  this  a  silver  plate  was  struck,  which  filled  accu- 
rately into  the  hollow  and  under  the  right  ala  of  the 
nose;  a  small  tongue  of  silver  was  adjusted  over  the 
bridge  of  the  nose,  and  on  to  this  the  spectacles  were 
subsequently  soldered.  An  artificial  cheek  and  eye  were 
then  modeled  in  wax  to  match  the  other  side  of  the 
face.  A  second  silver  plate  was  struck  upon  a  metal 
cast  taken  from  the  model,  soldered  to  the  inner  plate 
as  a  cover  is  fixed  to  a  box.  An  artificial  eye  was  then 
fixed  to  the  plate  in  the  proper  situation,  and  the  face 
portion  painted  flesh-color  and  japanned.  In  order  to 
keep  the  mask  in  position,  a  strong  wire,  fixed  to  the 
posterior  edge  of  the  artificial  cheek,  passes  around  the 
right  ear,  and  the  ear  pieces  of  the  spectacles  are  joined 
behind  the  head  by  an  elastic  band." 


CHAPTER   XIV 
SUBCUTANEOUS    HYDROCARBON   PROTHESES 

ALTHOUGH  the  subcutaneous  employment  of  oil  and 
liquefied  paraffin  has  been  known  for  some  years,  par- 
ticularly by  Corning,  who  refers  to  his  use  of  solidify- 
ing oils  in  surgery  in  an  article  published  in  1891,  no  ac- 
tual application  for  prothetic  purposes  was  made  until 
1900,  when  Gersuny  first  advocated  the  method.  In  his 
published  report  he  says  that,  "  if  vaselin,  which  at  the 
temperature  of  the  body  has  the  consistency  of  oint- 
ment, be  liquefied  by  heat  and  by  the  means  of  a  Pra- 
vaz  syringe  is  injected  into  dilatable  tissue  of  the 
human  body,  there  is  produced,  at  the  site  where  the 
injection  is  made,  a  tumefaction  whose  volume  corre- 
sponds to  the  quantity  of  vaselin  injected.  The  reac- 
tion which  results  from  the  procedure  is  insignificant 
and  the  mass  appears  to  rest  without  change  where  in- 
jected." 

This  subcutaneous  method  of  vaselin  injection  he  em- 
ployed in  the  case  of  a  young  girl  to  correct  a  saddle  or 
depressed  nose.  The  operation  was  purely  a  cosmetic 
one,  and  was  performed  on  May  8,  1900,  with  a  very  sat- 
isfactory result. 

From  the  time  of  the  appearance  of  Gersuny's  paper, 
"  Ueber  eine  Subcutane  Prothese,"  a  number  of  oper- 
ators, such  as  Halban,  von  Frisch,  Kapsammer,  Delan- 
gre,  Rohmer,  Stein,  and  others,  began  to  follow  the 
method  with  gratifying  results. 

Pfannenstiel,  shortly  after,  claimed  that  the  injection 
of  vaselin  was  not  wholly  without  danger,  and  that  pul- 

15  209 


210     PLASTIC   AND    COSMETIC    SURGERY 

inonary  embolism  had  been  observed  by  him  subsequent 
to  its  use.  Moszkowicz  denied  the  possibilities  of  such 
danger,  although  at  this  date  it  is  quite  evident  that 
there  are  many  objections  to  the  sole  use  of  sterile  vase- 
lin  for  all  subcutaneous  cosmetic  purposes  where  such 
protheses  might  be  indicated. 

Eckstein,  on  July  24,  1901,  rehearses  these  objections 
and  advocates  the  use  of  "  Hart  paraffin,"  or  paraffin 
with  a  melting  point  of  57-60°  C.  (140°  F.).  His  method 
was  taken  up  by  Broeckaert,  Baratoux,  Brindel,  Watson 
Cheyne,  Walker  Downie,  Leonard  Hill,  Lake,  Scanes 
Spicer,  Karewski,  and  other  prominent  surgeons  abroad, 
and  by  Parker,  Harmon  Smith,  Hamilton,  Quinlan,  Con- 
nell,  and  others  in  the  United  States. 

Drs.  Lynch  and  Heath  were  the  first  American  physi- 
cians to  place  themselves  on  record  in  the  employment 
of  the  method  of  Gersuny  for  the  correction  of  nasal 
deformities. 

Each  of  the  operators  employing  the  now  so- 
called  Gersuny  method  advanced  their  individual  ideas 
and  improvements  in  the  art,  and  those  of  distinctive 
merit  will  be  considered  later  by  the  author,  who 
has  employed  both  methods  from  the  time  of  their  in- 
cipiency. 

The  method  of  procedure  in  the  injection  of  vaselin 
or  paraffin  is  practically  similar,  except  for  the  various 
ways  in  which  the  paraffin  of  different  melting  points  is 
rendered  liquid. 

INDICATIONS 

The  indications  for  the  protheses  of  either  method 
are  the  same,  except  where  the  author  advocates  the  use 
of  either  one  or  the  other  or  a  combination  of  the  two 
from  an  experience  with  over  five  hundred  personally 
conducted  cases. 

The  advantages  of  the  Gersuny  method  is  that  the 
operation  is  practically  painless,  causes  no  scar  if  prop- 


FIG.  283. — CIRCULATION  OF  THE  HEAD. 


A,  Supra-Orbital  Vein. 

B,  Supra  Palpebral  Vein. 

C,  Angular  Vein. 

D,  Nasal  Vein. 

E,  Facial  Vein. 

F,  Temporal  Vein. 

G,  Ext. -Jugular  Vein. 
H,  Post-Auricular  Vein. 
I,  Occipital  Vein. 


J,  Post-Ext. -Jugular  Vein. 

K,  Sup.  Labial  Vein. 

L,  Inf.  Labial  Vein. 

M,  Transverse  Facial  Vein. 

N,  Communicating  Br.  Ophtal  Vein. 

O,  Angular  Artery. 

P,  Ant.  Temporal  Artery. 

Q,  Post  Temporal  Artery. 

R,  Sup.  Coronary  Artery. 


HYDROCARBON  PROTHESES      211 

erly  performed,  and  corrects  a  deformity  that  could  not 
be  overcome  otherwise  in  some  cases,  while  in  others 
it  would  entail  not  only  difficult  surgical  interferences, 
but  subsequently  unsightly  cicatrices  that  would  render 
them  more  objections!  than  the  very  defects  which  were 
intended  to  be  corrected. 

This  is  particularly  true  in  the  cosmetic  correction  of 
depressions  about  the  forehead  resulting  from  direct 
violence  or  frontal  sinus  operations,  for  obliterating 
habit  furrows,  or  frowns,  between  the  eyebrows;  also 
to  restore  the  symmetry  of  the  face  in  hollows  of  the 
cheek  due  to  the  removal  of  malignant  growths,  the 
maxillae,  or  when  caused  by  facial  hemiatrophy  or  a 
congenital  or  long-acquired  sinking  in  of  the  cheeks; 
while  it  may  also  be  employed  with  excellent  result  to 
prevent  post-operative  adhesions  about  the  face  after 
mastoid  operations  and  even  to  restore  the  form  of  the 
breast  after  operation  for  malignant  disease  and  the 
raising  of  smallpox  pits. 

Numerous  other  uses  may  be  mentioned,  such  as  ele- 
vating an  undue  depression  at  the  root  of  the  nose, 
raising  sunken  furrows  below  the  eyes,  obliterating 
nasolabial  folds,  angular  droops  about  the  chin,  rebuild- 
ing weak  or  pronounced  oval  or  peaked  chins,  filling 
hollows  about  the  neck  and  shoulders,  and  in  fact  any- 
where about  the  body  to  restore  the  contour. 

In  correcting  the  deformities  of  the  nose,  whether 
congenital  or  acquired,  this  method  has  met  an  urgent 
and  most  useful  demand,  so  much  so  that  many  rhino- 
plastic  operations  of  extensive  delicacy  have  been 
thrown  aside  for  this  simpler,  rapid,  and  gratifying 
means  of  surgery. 

Not  only  has  it  been  employed  to  restore  the  nasal 
line  in  saddle  noses,  but  also  in  many  other  deformities 
of  that  organ  which  do  not  require  the  removal  of  super- 
abundant tissue. 

According  to  the  appended  classification  of  nasal  de- 


formities,  given  by  Roe,  it  will  be  seen  that  many  faults 
of  that  organ  may  be  overcome  by  the  method. 

f  ,T    ,.    ,  (  Concave. 

Verticals  _. 

D        „     ,.  Convex. 

Bony  Portion  \ 

T    .      ,      bpatulated. 

lLateraM  Defected. 


Deformities  of  the  nose 


f  Excessive  or  Deficient 

C  Tip  J      Tissue- 

^    ,.,     .  |  Deviation  from  Me- 
Cartilagmous 

T,    ,.  •<  (.     dian  Line. 

Portion 

„,.  )  Collapsed. 

L  Wings  i  „      *T~, 

(  Expanded. 

From  the  above  arrangement,  and  taking  each  divi- 
sion separately,  the  author  enumerates  the  applicability 
of  the  subcutaneous  prothesis,  adding  such  as  are  not 
included  in  the  above. 

1.  Vertical  concavity.    An  overmarked  depression  at 
the  site  of  the  bony  structure  and  about  the  root  of  the 
nose. 

2.  Lateral  deficiency  of  form  about  the  root  of  the 
nose  extending  downward  as  far  as  the  inferior  borders 
of  the  nasal  bones. 

3.  Median  anterior  vertical  concavity  or  saddle  nose 
involving  the  middle  third,  otherwise  the  inferior  and 
superior  sections. 

4.  Deviations   of   the   cartilaginous    structure   about 
the  middle  third  of  the  nose,  either  unilateral  or  bilat- 
eral. 

5.  Deviation  of  the  lobule. 

6.  Deficiency  of  the  lobule. 

7.  Lobular  cleft. 

8.  Subseptal  cleft. 

9.  Collapsed  alae,  unilateral  or  bilateral. 
10.  Retraction  of  subseptum. 

In  these  ten  subdivisions  much  can  be  done  to  bring 
about  a  normal  appearance  of  the  nose. 


HYDEOOABBON   PBOTHESES  213 

PRECAUTIONS 

In  selecting  a  case  for  subcutaneous  injection  the 
operator  must  well  consider  the  methods  to  be  employed, 
his  successes  with  such  methods,  the  importance  and 
gravity  of  the  operation,  the  condition  of  the  patient, 
the  extent  of  the  deformity,  the  peculiarity  of  the  pa- 
tient and,  particularly,  the  state  of  mind  of  the  patient. 

While  at  this  date  of  the  use  of  this  method  of  beau- 
tifying parts  of  the  human  face  we  may  feel  certain 
of  the  happy  outcome  of  an  operation  undertaken  by  the 
operator,  he  must  not  lose  sight  of  the  hypercritical 
person  upon  whom  the  work  is  to  be  done;  even  with  an 
outcome  gratifying  in  the  extreme  from  a  surgical 
standpoint,  -the  patient  will  insist,  and  that  in  eighty 
per  cent  of  all  cases,  to  still  further  improve  them  in 
spite  of  the  fact  that  a  normal  appearance  has  been 
attained,  often  leading  the  operator  into  doing  what  he 
should  not  do,  and  eventually  undoing  his  own  excellent 
efforts. 

The  author  does  not  mean  to  imply  this  as  a  weak- 
ness on  the  part  of  the  surgeon,  but  cannot  impress  too 
deeply  upon  him  the  unreasonable  demands  of  a  person 
insanely  bent  upon  having  the  alabaster  cheek  ideal  of 
the  poets,  the  nose  of  a  Venus,  the  chin  of  an  Apollo, 
the  neck  of  swanlike  form,  etc. 

The  patient  believes  it  lies  in  the  power  of  the  cos- 
metic surgeon  to  do  with  their  malformations  as  a  sculp- 
tor would  model  in  clay  and  will  insist  upon  gaming 
their  ideal  beyond  all  reason. 

Let  the  author  warn  the  operator  against  the 
"  beauty  cranks,"  especially  of  those  who  are  just  about 
to  engage  in  great  theatrical  ventures,  circus  perform- 
ances, or  "  acts,"  and  very  desirable  marriages.  These 
are  patients  who  are  not  only  difficult  to  deal  with,  but 
the  first  to  harm  the  hard-earned,  well -deserved  reputa- 
tion of  the  surgeon  and  to.  drag  him  into  courts  for  re- 


214     PLASTIC    AND    COSMETIC    SUKGKEY 

imbursement  for  all  kinds  of  damages,  especially  backed 
up  by  events,  losses,  and  sufferings  largely  imaginable 
and  untrue,  and  ofttimes  entirely  impossible. 

In  all  cosmetic  surgery  this  branch  is  the  most  dan- 
gerous from  that  point  of  view;  therefore  the  operator 
should  take  his  case  well  in  hand,  proceed  with  an  un- 
shakable determination  and  give  the  patient  to  under- 
stand his  position,  even  to  explaining  what  disappoint- 
ments there  might  be  and  what  dangers,  if  any,  he  might 
look  forward  to.  The  author  believes  it  no  unjust  de- 
mand to  have  an  agreement  made  with  the  one  to  be 
treated  in  which  these  matters  are  fully  considered. 
Such  an  arrangement  will  save  him  much  worry  and 
will  tend  in  the  majority  of  cases  to  keep  his  patient  sat- 
isfied. 

On  the  other  hand,  the  operator  should  not  under- 
take to  do  an  operation  of  a  cosmetic  nature  unless  he 
has  a  fundamental  and  practical  experience  of  long 
standing  in  this  branch  of  surgery,  and  is  ready  at  all 
times  to  cope  with  such  post-operative  conditions  as  are 
likely  to  arise,  which  will  be  described  later. 

The  author  has  on  various  occasions  been  asked  to 
correct  the  most  hideous  malformations  of  parts  of  the 
face,  particularly  the  nose,  in  which  surgeons  of  high 
standing,  both  here  and  abroad,  had  injected  paraffin 
in  liquid  form,  usually  under  a  general  anesthetic,  the 
most  remarkable  being  that  of  a  hospital  orderly  in  the 
United  States  service,  who  had  been  subjected  to  not 
only  one  of  such  injections  to  correct  a  saddle  nose  under 
chloroform  anesthesia,  but  to  three  distinctive  opera- 
tions, with  the  result  of  a  permanent  disfigurement,  bet- 
tered only  by  a  succession  of  excisions  at  different  parts 
of  the  nose. 

Apropos  of  such  cases  it  may  be  timely  to  state  that 
a  general  anesthetic  for  the  performance  of  a  prothetic 
injection  operation  is  never  justifiable  and  should  be 
considered  a  lack  of  knowledge  on  the  part  of  the  oper- 


HYDROCARBON  PBOTHESES      215 

ator,  unless  its  use  be  advised  by  another  surgeon  in 
consultation. 

The  greatest  mistake  made  with  this  so-called  "fill- 
ing method  "  has  been  a  desire  on  the  part  of  the  patient 
or  the  operator,  or  both,  to  complete  the  work  too 
quickly.  Unscrupulous  operators  have  restored  a  sad- 
dle nose  or  the  contour  of  the  cheeks  in  a  few  minutes, 
when  it  is  an  established  fact  that  the  work  should  be 
done  slowly,  giving  time  for  the  injections  to  accommo- 
date themselves  and  to  organize  before  others  are  at- 
tempted. This  is  not  only  true  of  fillings  about  the 
cheeks  and  shoulders,  but  also  of  injections  about  the 
nose  and  forehead. 

Eschweiler  particularly  emphasizes  the  advocacy  of 
oft-repeated  injections,  and  the  author  recommends 
such  rule  without  reserve  or  deviation. 

THE  ADVANTAGE   OF  THE   METHOD 

As  has  been  said,  the  advantage  of  the  Gersuny 
method  over  other  procedures  is  that  it  can  be  under- 
taken practically  without  pain,  that  it  is  quick,  bloodless, 
leaves  no  scar,  and  is  harmless  except  under  such  condi- 
tions as  will  be  referred  to  under  a  separate  heading. 

While  the  method  entails  only  the  pain  of  a  pin 
prick  a  local  anesthesia  may  be  employed  to  overcome 
this,  but  never  a  general  anesthetic.  The  ethyl-chloride 
spray,  except  at  very  small  points  of  the  skin,  is  not  to 
be  recommended  because  it  freezes  and  consequently 
hardens  the  very  tissue  which  should  be  flexible,  the 
operation  being  undertaken  the  moment  the  needle  is 
inserted  and  lasting  only  a  few  seconds.  The  hypoder- 
mic use  of  a  two-per-cent  solution  of  cocain,  or  better 
Eucain  fi,  can  be  employed,  but  the  author  sees  no  advan- 
tage in  it,  as  the  hyperemic  engorgement  following  its 
use  obliterates,  to  a  certain  degree,  the  actual  extent  of 
the  deformity. 


216     PLASTIC    AND    COSMETIC    SURGERY 

It  is  desirable  to  obtain  the  best  result  to  have  the 
skin  above  the  part  as  free  as  possible.  When  closely 
adherent  it  should  be  freed  by  the  careful  use  of  a  deli- 
cate tenotome,  inserted  at  the  point  where  the  injection 
is  to  be  made,  the  same  opening  being  used  for  the  in- 
troduction of  the  needle  of  the  syringe.  If  this  opening 
has  been  made  too  large  a  fine  suture  of  silk  should 
be  employed  to  bring  the  lips  of  the  wound  together 
before  the  injection  is  made;  the  needle  point,  being 
knife-edged,  will  not  disturb  the  apposition  and  will  tend 
to  retain  the  filling  if  no  undue  pressure  is  used,  as  in 
the  case  of  hyperinjection. 


UNTOWARD  RESULTS 

Connell  has  tabulated  the  difficulties  and  dangers  met 
with  in  this  work  as  follows : 

1.  Toxic  absorption. 

2.  Marked  inflammatory  reaction. 

3.  Loss  of  tissue,  due  to  infection  and  abscess  for- 

mation. 

4.  Pressure  necrosis,  caused  by  hyperinjection. 

5.  Sloughing  of  tissue  as  a  result  of  the  heat  of 

paraffin. 

6.  Injection  into  very  dense  or  inelastic  structures, 

or  where  scar  tissue  is  firmly  attached  to  the 
underlying  and  adjacent  parts. 

7.  Subinjection  of  too  small  an  amount  of  paraffin 

with  an  insufficient  correction  of  the  deformity. 

8.  Hyperinjection  with  overcorrection  of  deformity. 

9.  Air  embolism. 

10.  Paraffin  embolism. 

11.  Primary  diffusion  or  extension  of  paraffin  (when 

first  introduced)    into   adjacent  normal  struc- 
tures. 

12.  Interference  with  muscular  action  of  the  nose. 


HYDROCARBON    PROT11ESBS  217 

13.  Escape  of  paraffin  after  the  withdrawal  of  the 

needle  or  primary  elimination. 

14.  Solidification  of  the  paraffin  in  the  needle,  which 

renders  the  injection  difficult  and  causes  inju- 
dicious expedition  on  the  part  of  the  operator. 

15.  Absorption  or  disintegration  of  the  paraffin. 

16.  The  difficulty  of  procuring  paraffin  at  the  proper 

melting  point. 

17.  Hypersensitiveness  of  the  skin  over  the  injected 

area. 

18.  Redness  of  the  skin  over  the  injected  area. 

To  those  the  author  would  add : 

19.  Secondary  diffusion  of  the  injected  mass. 

20.  Hyperplasia  of  the  connective  tissue  following 

the  organization  of  the  injected  matter. 

21.  A  yellow  appearance  and  thickening  of  the  skin 

after  organization  of  the  injected  mass. 

22.  The  breaking  down  of  tissue  and  the  resulting 

abscess  due  to  the  pressure  of  the  injected 
mass  upon  the  adjacent  tissue  after  the  injec- 
tion has  become  organized. 

Each   of   the   above   subdivisions   may  be   advanta- 
geously considered  individually,  to  wit: 

1.  Intoxication. — The  danger  of  intoxication  may  truly 
be  said  to  be  more  so  due  to  the  unclean  or  unsterilized 
matter  injected  than  to  the  absorption  following  its  em- 
ployment, although  Meyer  has  claimed  untoward  symp- 
toms found  in  his  experiments  from  absorption  of  in- 
jections of  vaselin  in  the  animal.  Taddie  and  Delain, 
Stubenrath,  Straume,  Sobieranski,  and  Dunbar  have 
corroborated  this  claim.  They  injected  paraffin  of  vari- 
ous melting  points  in  the  lower  animals  and  observed 
results  therefrom,  among  which  were  loss  of  hair,  a  re- 
duction of  eighteen  per  cent  in  the  body  weight  in  two' 
months  and  death. 


218      PLASTIC    AND    COSMETIC    SUKGERY 

Stein  and  Harmon  Smith  refute  these  conditions  and 
remarked  neither  systemic  nor  local  untoward  results 
from  such  injections  when  paraffin  of  higher  melting 
points  were  used. 

Jukuff  claims  that  no  toxic  symptoms  resulting  from 
the  absorption  of  paraffin  injected  into  tissues  are 
shown,  unless  the  amount  be  equal  to  ten  per  cent  of 
the  weight  of  the  animal.  To  have  this  apply  to  the 
human  as  much  as  ten  to  fifteen  pounds  would  have  to 
be  injected — an  amount  never  required  in  operations  of 
this  nature. 

While  it  cannot  be  denied  that  the  injected  mass  be- 
comes more  or  less  absorbed  in  from  two  to  three 
months  and  is  replaced  by  connective  tissue,  it  may  be 
definitely  stated  that  no  toxic  symptoms  are  caused 
directly  thereby,  except  by  the  employment  of  an  impure 
product. 

2.  Reaction. — The  reaction  following  a  properly  made 
injection  is  of  a  mild  inflammatory  character.     Consid- 
erable inflammation  points  to   some  fault  in  the  tech- 
nique or  impurity  of  the  injection.    More  or  less  edema 
of  the  site  and  its  adjacent  area  may  be  noted,  associ- 
ated with  slight  or  marked  discoloration  and  pain  of 
variable  degree.     The  normal  reaction  following  the  in- 
jection is  temporary  and  does  not  necessitate  treatment 
or  confinement  of  the  patient,  who  can  resume  the  duties 
of  life  fifteen  hours  after  the  operation. 

3.  Infection. — The  cause  of  infection  cannot  be  said  to 
be  due  to  anything  but  surgical  uncleanliness,  as  it  is 
with  any  surgical  undertaking,  and  can  be  overcome  by 
the  same  means. 

The  material  injected  should  be  thoroughly  steril- 
ized by  boiling  before  using.  Broeckaert  suggests  com- 
bining an  antiseptic  with  the  paraffin  and  has  used 
guiaform,  a  combination  of  formic  aldehyde  and 
guiacol  in  a  proportion  of  five  to  ten  per  cent;  yet 
this  is  of  little  value  when  we  consider  how  read- 


219 

ily  these  hydrocarbons  can  be  rendered  sterile  at  high 
temperatures. 

4.  Necrosis. — Death  of  tissue  may  follow  an  injection 
of  paraffin  when  too  much  pressure  has  been  applied,  or 
when  too  much  has  been  injected  into  the  tissue,  cutting 
off  the  blood  supply,   or  when  the  injection  has  been 
made  into  the  skin  instead  of  beneath  it.     Again,  con- 
stitutional disease,  such  as  diabetes  or  Bright's  disease, 
may  superinduce  the  breaking  down  of  the  tissue. 

Hyperinjection  should  and  can  be  avoided  by  the  use 
of  the  proper  instrument  with  which  the  required 
amount  is  graduated  to  a  nicety.  At  no  time  should  an 
injection  be  crowded  into  a  dense  tissue  or  where  the 
skin  is  closely  adherent,  nor  carried  so  far  as  to  create 
a  blanching  of  the  skin.  By  carefully  injecting  the  mass 
this  danger  should  be  overcome. 

Dense  or  bound-down  areas  of  skin  should  be  loos- 
ened and  freed,  as  has  already  been  mentioned. 

If  care  be  exercised  and  small  amounts  be  injected, 
in  preference  to  overcoming  the  defect  in  one  sitting, 
pressure  effects  are  entirely  overcome. 

The  circulation  in  the  skin  over  the  site  of  injection 
should  be  normal  immediately  after  the  operation  has 
been  performed,  determined  by  observing  the  reaction- 
in  the  color  of  the  skin  after  delicate  digital  pressure. 

5.  Sloughing. — That   sloughing  of  the  skin  should  be 
occasioned  by  the  high  temperature  of  the  paraffin  in- 
jected is  a  condition  entirely  inexcusable.     Paraffin  of 
high  melting  points  58°  to  65°  C.,  or  the  so-called  "  Hart 
paraffin"  employed  by  Wolff,  liquefying  at  from  57° 
to  60°   C.,  are  to  be  used  with  caution.     The  author 
doubts  whether  the  temperature  of  the  paraffin  at  the 
time  of  injection,  even  in  the  latter  method,  is  ever  be- 
yond 54°  C.  even  if  the  thermometer  registers  60°  C. 
in  the  liquefying,  hot-water  bath. 

By  the  time  it  has  been  drawn  into  the  syringe,  which 
has  been  heated  by  dipping  into  hot  water,  and  the 


220      PLASTIC    AND    COSMETIC    SURGERY 

moment  it  is  injected  it  has  lost  several  degrees  in 
heat. 

It  would  not  be  permissible  to  inject  a  molten  mass 
of  a  temperature  so  high  as  to  scar  or  burn  the  tissues, 
and  the  best  results  of  most  operators  have  been  ob- 
tained with  such  of  the  paraffin  group  that  become  lique- 
fied at  a  temperature  of  not  over  45°  C.  (112°  F.). 

The  claim  of  Eckstein,  that  paraffins  of  low  melting 
points  are  more  likely  to  be  absorbed,  has  not  been  sub- 
stantiated in  actual  practice,  since  we  now  know  that 
any  and  all  of  these  injections,  irrespective  of  their  melt- 
ing points,  are  absorbed  in  time,  giving  place  to  con- 
nective tissue,  and  that  rarely,  if  ever,  is  there  a  true 
and  complete  encapsulation  or  encystment  of  the  mass 
thus  introduced.  Even  the  hard  paraffins  are  split  up  in 
time  into  minute  pearllike  particles  which  are  displaced 
by  the  growth  of  tissue  arising  from  the  presence  of 
the  foreign  substance.  This  is  true  even  in  those  cases 
in  which  the  author  has  introduced  by  surgical  means 
solid  paraffin  plates  in  the  cold  state. 

6.  Sloughing  Due  to  Pressure. — When  an  injection  is 
forced  into  a  dense  or  firmly  bound-down  tissue,  as  into 
the  body  of  a  thickened  cicatrix,  or  about  the  point  of 
the  nose  or  the  subseptum  of  the  nose  without  first  dis- 
secting off  the  skin  above  the  subcutaneous  layers,  an 
acute  anemia  is  at  once  marked,  followed  by  inflamma- 
tion and  gangrene. 

By  injecting  sterile  water  into  the  area  thus  loos- 
ened with  the  knife  a  good  idea  of  the  thoroughness  of 
the  dissection  and  the  possibility  of  building  up  the  part 
to  be  corrected  is  obtained,  yet  in  these  cases  the  author 
has  always  found  more  or  less  difficulty  in  keeping  the 
injected  mass  in  place  for  the  reason  that  the  divided 
surfaces  tend  to  unite  at  their  peripheral  borders', 
crowding  the  mass  upward  or  to  one  side  or  diffusing  it  in 
such  a  way  that  the  result  has  been  anything  but  satis- 
factory. 


HYDROCARBON  PROTHESES      221 

To  overcome  this  it  is  advisable  to  inject  a  smaller 
quantity  than  necessary  to  entirely  correct  the  defect,  to 
mold  it  out  flat  and  to  allow  it  to  organize  before  more 
is  introduced. 

7.  Subinjection. — Insufficient    injection    leading    to    an 
undercorrection  of  the  defect  is  a  far  more  desirable 
condition  than  hyperinjection,   and  is   easily  corrected 
by  a  repetition  of  the  treatment,  even  to  a  third  sitting, 
until  the  desired  result  is  obtained.    Following  this  rule 
will  give  far  better  results,  as  has  been  said,  than  to  be 
compelled  to  remove  a  part  of  the  filling  and  some  of  the 
connective  tissue  which  has   resulted  therefrom. 

8.  Hyperinjection. — The  injection  of  too  much  vaselin 
or  paraffin  is  one  of  the  most  common  faults  found  with 
operators.     In  the  first  instance  a  tumefaction  of  the 
site   results   which   with   the   production   of   the   tissue 
which  takes  the  place  of  part  of  the  filling  makes  the 
result  very  unsatisfactory  and  requires  one  or  more  cut- 
ting operations  to  reduce  it.    A  peculiar  fact  with  these 
hyperplastic  growths  is  that  even  though  they  may  be 
reduced  with  the  knife  to  a  normal  size  they  seem  to 
redevelop  again  and  again,  giving  both  surgeon  and  pa- 
tient great  concern. 

This,  in  the  opinion  of  the  author,  is  due  to  the  bind- 
ing down  of  the  marginal  borders,  which,  in  the  event 
of  partial  extirpation,  are  not  injured  sufficiently  to  dis- 
place them  and  that  they  unite  again  in  their  former 
position.  To  overcome  this  it  is  found  best  to  excise 
the  entire  filling  much  beyond  the  margins  and  to  apply 
pressure  over  the  area  until  perfect  union  has  taken 
place. 

This  is  best  accomplished  with  a  disk  of  aluminium, 
bent  to  conform  to  the  shape  of  the  part  operated,  lined 
with  sterilized  lint  and  fixed  over  the  site  by  strips  of 
Z.  O.  plaster. 

While  the  hyperinjection  of  vaselin  is  not  as  objec- 
tionable as  that  of  paraffin,  because  of  the  more  ready 


222      PLASTIC    AND    COSMETIC    SURGERY 

accommodation  and  absorption  of  the  mass,  it  never- 
theless leads  to  diffusion  of  the  material,  owing  to  its 
softer  consistency  and  consequent  greater  facility 
in  seeking  fine  avenues  of  escape,  paraffin  having  the 
advantage  of  cooling  upon  itself  en  masse,  leaving  little 
to  escape  into  undesirable  channels  after  it  has  once 
been  molded  and  set. 

Vasserman  cites  a  case  in  which  gangrene  of  the 
bridge  of  the  nose  resulted  after  an  injection  of  2.05  c.c. 
of  vaselin. 

However,  when  these  faults  occur  they  are  errors 
of  technique,  and  should  be  avoided,  as  has  been  men- 
tioned heretofore. 

The  removal  of  such  hyperinjected  masses  by  the  aid 
of  paraffin  solvents,  such  as  benzine,  ether,  chloroform, 
or  xycol,  applied  to  the  skin  above  the  filling,  has  proved 
a  failure,  nor  will  heat  used  externally  in  the  same  man- 
mer  remedy  evil. 

What  is  left  to  the  operator  is  to  open  the  skin  and, 
with  a  small,  sharp  spoon  curette,  remove  the  mass 
early,  before  it  has  become  organized,  or  to  excise  the 
new  connective  tissue  and  the  broken-down  filling,  as 
mentioned. 

When,  however,  the  tumefaction  resulting  from  such 
hyperinjection  is  not  extensive,  as  is  often  found  about 
the  chin  and  at  the  root  of  the  nose,  the  secondary  de- 
formity can  be  materially,  if  not  entirely,  remedied  by 
electrolysis.  A  needle  or  brooch  of  certain  hardness  is 
to  be  employed,  connected  with  the  negative  pole  of  a 
continuous  current  apparatus.  From  twelve  to  twenty 
milliamperes  are  required.  The  process  is  similiar  to 
that  used  with  the  destruction  of  hair,  naevi,  or  moles  on 
the  face.  The  needle  should  puncture  the  entire  tumor 
or  penetrate  its  maximum  diameter  and  be  charged  with 
the  current  for  two  or  three  minutes.  Several  of  such 
punctures  should  be  made  at  each  sitting,  the  latter  being 
repeated  as  often  as  is  deemed  necessary  by  the  opera- 


HYDROCARBON  PROTHESES      223 

tor.  The  reaction  which  follows  this  procedure  is  of 
little  moment,  and  these  sittings  can  be  undertaken 
every  three  or  four  days. 

While  this  method  is  liable  to  leave  little  punctuate 
scars  at  the  sites  where  the  needle  is  introduced,  it  is 
nevertheless  more  satisfactory  than  the  linear  scar 
made  with  the  knife,  to  the  use  of  which  the  patient 
may,  on  the  other  hand,  object,  not  to  speak  of  the 
difficulty  and  unsatisfactory  results  usually  obtained 
therewith. 

9.  Air  Embolism. — The  fault  of  introducing  air  under 
the  skin  with  the  syringe  at  the  time  of  injection  can 
only  be  the  result  of  flagrant  negligence.    Every  physi- 
cian should  know  enough  to  hold  the  syringe  in  an  erect 
or  vertical  position,  and  to  expel  the  air  above  the  solu- 
tion in  his  syringe,  as  is  done  with  any  hypodermic  in- 
jection. 

Air  embolisms  are  also  occasioned  by  a  careless  fill- 
ing of  the  syringe  with  the  hydrocarbon  in  a  cold  state, 
as  the  material  is  now  generally  used,  and  while  the 
dangers  of  such  emboli  are  very  much  exaggerated  they 
should  not  be  permitted,  when  by  the  pouring  in  of  the 
liquefied  material  the  syringe  can  be  filled  evenly. 

Practically  there  is  no  harm  done  by  the  injection  of 
air  under  the  skin,  yet  it  elevates  the  skin  at  the  site 
of  the  defect  and  hinders  the  surgeon  in  accomplishing 
the  best  results. 

These  emboli  cause  a  bulging  up  of  the  skin  for  the 
time  being  and  may  occasion  more  or  less  pain  to  the 
patient,  which  passes  away  in  ten  or  twelve  hours,  leav- 
ing the  parts  as  injected  except  for  such  reactionary 
symptoms  or  edema,  already  referred  to. 

10.  Paraffin  Embolism. — The  creation  of  an  embolism  is 
invariably  due  to  an  injection  of  the  foreign  substance 
directly  into  a  blood  vessel.    This  condition  is  one  of  the 
most  objectionable,  if  not  the  most  dangerous,  factor  as- 
sociated with  the  subcutaneous  injection  of  any  foreign 


matter,  be  it  a  liquid  substance,  as,  for  instance,  an  oil; 
many  cases  have  been  placed  on  record  where  they  have 
been  observed  after  the  introduction  of  even  paraffin 
of  high  melting  points,  when  introduced  under  the  skin 
in  hot  liquid  state.  Consequently  the  use  of  vaselin 
liquefied  by  the  aid  of  heat  is  especially  liable  to  give 
rise  to  such  condition. 

Pfannenstiel  cites  a  case  wherein  he  injected  paraffin 
in  which  the  patient  was  at  once  attacked  with  violent 
coughing,  and  for  three  days  exhibited  symptoms  of 
grave  nature,  such  as  pain  in  side,  intense  dyspnea,  ac- 
celeration of  the  pulse,  hyperthermia,  cyanosis  of  the 
face,  hemoptysis,  violent  cephalalgia,  and  vomiting — all 
indications  of  pulmonary  and  cerebral  embolism.  The 
injection  in  this  case  was  one  of  30  c.c.  of  paraffin,  with 
a  melting  point  of  45°  C.  The  symptoms  as  mentioned 
continued  for  about  one  week,  gradually  subsiding,  and 
followed  by  recovery. 

Kapsammer  has  also  noticed  such  symptoms. 
Leiser,  after  injecting  vaselin  to  correct  a  saddle  nose, 
noted  an  immediate  collapse  of  the  patient,  which  was 
obviated  only  by  the  hypodermic  use  of  ether  and  the 
resort  to  artificial  respiration.  When  the  patient  re- 
turned to  consciousness,  he  was  found  to  be  entirely 
blind  in  the  right  eye,  the  eye  before  the  operation  hav- 
ing been  known  to  show  only  a  pronounced  astigma- 
tism. 

Kofman  cites  the  loss  of  a  patient  from  the  injection 
of  10  c.c.  of  paraffin  for  vaginal  prolapsis.  Moskowicz 
observed  two  cases  of  pulmonary  embolism  treated  in 
the  same  manner,  stating  that  an  alarming  dyspnea  con- 
tinued for  several  hours. 

Especially  have  cases  in  which  the  injections  of  par- 
affin were  made  submucously  for  the  correction  of 
atrophic  coryza  shown  embolic  tendencies.  This  is  es- 
pecially true  when  paraffins  of  high  melting  points  have 
been  employed,  as  in  the  case  of  Pfannenstiel,  in  which 


HYDROCARBON  PROTHESES      225 

instance  the  condition  of  the  mass  permitted  of  freer 
absorption  or  the  high  temperature  caused  a  coagula- 
tion of  the  blood  in  the  veins,  leading  to  thrombosis  and 
embolism,  and  when  the  amount  of  such  an  injection 
is  so  large  as  to  prevent  cooling  and  hardening  in  the 
normal  space  of  time  added  to  the  quantity  and  associ- 
ated at  the  same  time  with  consequent  pressure,  pre- 
disposing to  absorption  or  dissemination,  especially  if 
the  injection  be  made  into  the  parenchymatous  instead 
of  the  subcutaneous  tissue. 

Comstock,  in  his  experience  on  animals,  states  that 
"  in  all  cases  in  which  paraffin  was  used  at  102°  F.  the 
animals  died  within  two  weeks'  time,  hence  the  speci- 
mens at  that  temperature  are  limited  (death  being  by 
thrombosis).  In  all  other  cases  with  the  higher  melt- 
ing point,  110°  F.,  no  unpleasant  results  were  experi- 
enced." 

Hurd  and  Holden  have  observed  a  patient  who  had 
previously  undergone  two  injections  of  paraffin  for  the 
correction  of  a  depression  in  the  upper  part  of  the  nose. 
A  third  injection  was  advised  and  made  under  the  same 
conditions  as  the  first,  except  that  no  cocain  anesthesia 
was  employed,  the  paraffin  being  at  same  temperature 
as  before. 

The  moment  the  injection  was  made  complete  blind- 
ness in  the  right  eye  resulted,  while  a  small  ecchymotic 
spot  appeared  at  the  site  of  the  needle  insertion  in  the 
skin.  Half  an  hour  later  an  examination  of  the  eye 
showed  the  right  pupil  dilated  and  inactive  light  stim- 
ulus, the  patient  being  unable  to  distinguish  light  from 
darkness.  Ophthalmoscopically  the  lower  branch  of  the 
central  retinal  artery  and  its  subdivisions  were  found 
to  be  empty  and  in  a  state  of  collapse,  evidenced  by 
their  pale  appearance.  The  upper  branch  of  the  same 
vessel  was  found  to  be  poorly  filled. 

The  authors  endeavored  to  remove  the  embolism  to 
a  collateral  branch  of  the  artery  by  the  use  of  amyl 

16 


226     PLASTIC    AND    COSMETIC    SURGEEY 

nitrate,  digitalis,  and  pressure  on  the  globe  of  the  eye, 
with  no  effect.  Some  hours  later  edema  of  the  retina 
appeared,  followed  by  permanent  loss  of  sight.  The 
same  authors  have  observed  several  cases  of  pulmonary 
embolism  result  from  the  injection  of  paraffin. 

It  is  also  a  fact  that  injections  of  the  nature  being 
considered,  while  not  causing  immediate  embolism,  may 
do  so  as  a  result  of  phlebitis,  caused  by  a  direct  injec- 
tion into  the  vein  or  over  or  upon  it  in  such  a  way  as 
to  cause  irritation. 

Mintz  reports  a  third  case  of  amaurosis  following  a 
paraffin  injection.  The  latter  was  made  to  correct  a 
saddle  deformity  caused  by  syphilis.  Three  minutes 
after  the  injection  the  patient  complained  of  pain  in  the 
left  eye,  which  was  followed  by  total  blindness,  vom- 
iting, and  a  pulse  of  48.  Several  days  later  there  ap- 
peared symptoms  of  venous  congestion  in  the  orbit, 
paralysis  of  the  ocular  muscles,  corneal  cloudiness,  and 
exophthalmos,  a  small  gangrenous  spot  appeared  at  the 
site  of  the  injection. 

Broecksert  observed  a  case  of  facial  phlebitis,  fol- 
lowed by  pulmonary  infarction.  Brindel  cites  a  case 
in  which  he  observed  a  hard  line  of  considerable  extent 
and  painful  to  the  touch,  extending  from  the  inner  angle 
of  the  eye  to  the  angle  of  the  eye,  where  it  deviated  to- 
ward the  root  of  the  nose  and  terminated  at  the  origin  of 
the  eyebrow. 

De  Cazeneuve  made  an  injection,  and  on  the  follow- 
ing day  noted  that  the  right  cheek  had  increased  consid- 
erably in  size  with  an  elevation  of  temperature  in  the 
part.  Two  days  after,  under  the  right  eye  and  to  the 
right  of  the  nose,  the  whole  cheek  was  red,  hot,  and  much 
distended,  giving  the  skin  a  glazed  appearance.  Pal- 
pation was  extremely  painful.  A  hard  line  could  be 
made  out,  extending  from  the  inner  angle  of  the  eye 
outward  and  downward  under  the  lower  eyelid  and  ter- 
minating in  the  center  of  the  edematous  cheek.  The 


HYDROCARBON  PROTHESES      227 

phlebitis  in  this  case  resulted  without  the  development 
of  an  embolism. 

After  a  careful  study  of  the  causes  of  such  embolisms 
we  come  to  the  conclusion : 

1.  That  the  injected  mass  should  not  be  heated  above 
a  certain  melting  point. 

2.  That  hyperinjection  should  at  all  times  be  avoided, 
particularly  with  paraffins  of  high  melting  points. 

3.  That  the  injection  should  be  made  subcutaneously 
not  into  parenchymatous  tissues,  and 

4.  That  a  puncture  of  a  vein  or  the  introduction  of 
the  injected  mass  into  a  vein  should  be  avoided. 

In  the  consideration  of  the  first  two  causes  the  au- 
thor advocates  using  injections  of  low  melting  points 
only  at  all  times;  in  fact,  from  his  experience  with  over 
two  thousand  subcutaneous  injections,  he  relies  entirely 
upon  such  paraffins  or  hydrocarbon  mixtures  as  are 
semisolid  at  70°  F.,  appearing  as  a  white  cylindrical 
thread  from  the  needle  of  the  syringe  as  pressure  is 
applied. 

With  such  a  preparation  and  a  careful  introduction 
of  the  needle,  as  described  later,  and  with  the  injection 
of  an  amount  much  less  than  that  needed  to  correct  the 
deformity  and  proper  digital  compression  on  the  blood 
vessels  and  about  the  site  of  the  injection  embolism  is 
practically  impossible. 

The  avoidance  in  the  third  instance  is  self-evident, 
and  it  is  to  the  fourth  fault  and  cause  that  we  must  pay 
particular  attention. 

Stein  says  that  all  that  is  necessary  to  avoid  punctur- 
ing a  vein  is  to  first  introduce  the  needle  alone  under 
the  skin  and  to  attach  the  syringe  only  when  it  is  found 
no  flow  of  blood  results  from  the  puncture  thus  made. 

Freeman  and  the  author  add  to  this  by  advocating  the 
use  of  a  somewhat  blunt-pointed  needle  instead  of  the 
extremely  sharply  pointed  knife-edged  needles  usually 
furnished  with  syringes  intended  for  this  purpose. 


228      PLASTIC    AND    COSMETIC    SURGERY 

11.  Primary  Diffusion  or  Extension  of  Paraffin. -- The 
spreading  of  paraffin  into  normal  tissues  about  the  site 
to  be  corrected  by  prothetic  injection  is  a  fault  due 
principally  to  a  careless  use  of  the  syringe.  The  em- 
ployments of  an  improper  syringe  in  which  the  amount 
to  be  injected  cannot  be  graduated  or  controlled  will  be 
considered  later — the  result  with  such  being  hyper- 
injection.  In  this  event,  when  the  anterior  line  of  the 
nose  is  to  be  restored,  the  mass  is  liable  to  find  its  way 
into  the  loose  areolar  tissue  of  the  infra-orbital  region; 
in  correcting  a  nasolabial  furrow  the  mass  is  pushed 
upward  or  is  forced  into  the  tissue  of  the  cheek  above  it, 
aggravating  the  trouble;  in  obliterating  a  frown  it  trav- 
els upward  toward  the  margin  of  the  scalp,  giving  a 
median  prominence  to  the  forehead  that  is  found  to  be 
very  difficult  to  correct;  in  injections  about  the  mouth 
the  mass  moves  down  upon  the  chin  or  accumulates  at 
the  angle  of  the  jaw;  in  correcting  the  creases  beneath 
the  chin  it  seeks  the  sides  of  the  neck,  even  traveling 
to  the  superior  border  of  the  clavicle  at  its  sternal  third. 
Many  other  forms  of  such  diffusions  can  be  mentioned 
directly  due  to  primary  diffusion  the  result  of  hyper- 
injection. 

Enough  has  been  said  of  the  danger  of  hyperinjec- 
tion,  yet  even  with  a  proper  amount  of  the  injected  mass 
this  distention  may  be  observed.  To  avoid  this  the 
operator,  or  his  assistant,  should  compress  the  margins 
of  the  site  of  the  injection  with  his  fingers  firmly  ap- 
plied, as,  for  instance,  in  the  injection  of  the  root  of  the 
nose  pressure  should  be  made  at  both  inner  canthi  and 
ovei  the  tissue  just  above  the  root  of  the  nose  and  be- 
neath the  finger  tips. 

Downie  advocates  the  use  of  celloidin  in  the  correc- 
tion of  a  saddle  nose  as  follows:  He  paints  a  band  of 
celloidin  or  collodion  down  each  side  of  the  nose,  limited 
by  the  line  of  junction  with  the  cheeks,  and  another  band 
across  the  root  of  the  nose.  These  painted  on  bands  he 


HYDROCARBON  PROTHESES      229 

allows  to  dry  and  contract  for  fifteen  minutes  before 
undertaking  the  injection. 

The  contraction  of  these  bands  prevents  to  a  certain 
extent  the  spreading  or  extension  of  the  liquid  paraffin 
into  the  cellular  tissue  about  the  eyes,  yet  experienced 
digital  pressure  is  at  all  times  to  be  preferred. 

If  a  liquid  paraffin  or  hydrocarbon  mixture  or  vase- 
lin  is  used,  the  immediate  use  of  ice  cloths  applied  to 
the  part  as  digital  pressure  is  removed,  is  advisable  to 
aid  in  the  rapid  hardening  or  setting  of  the  injected 
mass  before  the  tension  of  the  tissues  over  and  about  it 
might  influence  it.  With  semisolid  injection  this  is  not 
necessary,  except  in  the  subsequent  treatment,  as  will 
be  considered  later,  because  the  mass,  unless  of  too  soft 
a  consistency,  as,  for  instance,  vaselin,  will  practically 
remain  as  injected  and  molded. 

Vaselin  when  injected  into  tissue  where  there  is  ten- 
sion would  naturally  be  forced  out  of  position  and  shape, 
and  should  not  be  used  except  in  combination  with  a 
paraffin  of  a  melting  power  high  enough  to  give  the 
proper  consistency  to  the  former. 

12.  Interference  with  Muscular  Action  of  the  Wings  of  the 
Nose. — That  nasal  respiration  may  be  encroached  upon 
as  a  result  of  injecting  paraffin  about  the  nose  has  been 
observed  by  Alter.  He  points  out  that  during  nasal  in- 
spiration there  is  a  tendency  for  the  alae  to  contract 
upon  themselves  or  to  move  inward,  decreasing  the 
lumen  of  the  orifice,  and  that  in  the  normal  state  this 
movement  is  counteracted  by  the  action  of  dilator  mus- 
cles of  the  alae — that  is,  the  dilator  naris  anterioris,  the 
pyramidalis  nasi,  and  the  levator  labii  superioris  alaeque 
nasi — and  that  this  muscular  action  is  interfered  with 
owing  to  the  pressure  of  the  paraffin  upon  these  delicate 
structures,  and  resulting  in  more  or  less  permanent  col- 
lapse or  indrawing  of  the  alae  during  inspiration.  He 
observed  considerable  interference  with  inspiration  in  a 
case  cited  in  which  an  injection  of  paraffin  had  been  made. 


230     PLASTIC    AND    COSMETIC    SUKGEHY 

To  avoid  undue  pressure  upon  the  structures  re- 
ferred to,  it  is  advised  to  have  an  assistant  place  a 
thumb  into  each  nostril  and  the  index  fingers  without 
and  above  the  alae  in  such  way  that  the  tips  of  the  ringers 
may  be  enabled  to  exert  the  necessary  pressure  over  the 
injected  mass  into  these  structures,  and  to  maintain  this 
pressure  until  the  mass  has  been  properly  molded  and 
set.  Connell  advises  inserting  the  little  fingers  into  the 
nostril  to  prevent  an  encroachment  on  the  lumen  of  the 
nasal  canal. 

The  above  applies  particularly  to  those  cases  where 
injections  are  made  into  the  anterior  lower  or  lateral 
third  of  the  nose,  as,  for  instance,  in  overcoming  slight 
depressions  in  the  anterior  line,  immediately  above  the 
lobule  or  in  a  low  unilateral  deviation  of  the  nose. 

13.  Escape  of  Paraffin  after  Withdrawal  of  Needle. — When 
the  injected  mass  employed  is  of  a  semisolid  consistency, 
as  heretofore  advised,  it  is  hardly  possible  for  the  mass 
to  be  forced  out  through  the  opening  of  the  skin  made  by 
the  introduction  and  withdrawal  of  the  needle,  unless 
there  be  an  unwarrantable  immobility  of  the  skin  above 
the  site  to  be  injected.  The  latter  should  be  corrected 
before  injection. 

The  mass  after  having  been  molded  in  the  shape  de- 
sired may  be  further  hardened  and  set  by  the  applica- 
tion of  ice  cloths  or  spraying  with  ether  before  the 
needle  is  withdrawn  from  the  skin,  yet  this  is  hardly 
necessary,  and  the  author  advises  against  the  practice 
for  the  reason  that  pressure  of  the  needle  prevents 
proper  and  free  molding  of  the  mass  and  renders  the 
tissue  liable  to  further  injury  by  scraping  its  point  to 
and  fro  subcutaneously,  adding  to  the  extent  of  the 
wound  and  the  dangers  of  infection  and  repair. 

The  skin  immediately  around  the  needle  hole,  after 
withdrawal  of  the  needle,  may  be  gently  smoothed  out 
with  the  dull  rounded  metal  handle  end  of  the  bistoury 
to  free  the  interdermal  canal  of  any  foreign  matter. 


HYDRQCABBON  PEOTHESES      231 

The  skin  about  the  needle  hole  is  then  gently  washed 
with  a  fifty-per-eent  solution  of  hydrogen  peroxid,  dried 
with  a  sterile  cotton  sponge  and  the  opening  sealed  with 
a  drop  of  collodion.  Subsequent  treatment  of  the  parts 
will  be  considered  later. 

14.  Solidification  of  Paraffin  in  Needle. — This  occurs  only 
when  paraffins  of  high  melting  points  are  employed  in 
liquid  form  in  the  syringe,  and  is  due  to  the  rapid  cool- 
ing of  the  paraffin  in  the  small  metallic  cannulae,or  needle, 
wherein  it  sets  more  readily,  since  the  volume  contained 
therein  is  very  small,  often  not  more  than  two  or  three 
drops. 

This  cooling  establishes  a  pluglike  formation  in  the 
distal  end  of  the  needle,  which  prevents  a  proper  use 
of  the  syringe,  often  breakage,  and  when  suddenly  liber- 
ated by  an  extra  pressure  on  the  piston  rod  causes  a 
rapid  discharge  of  the  contents  of  the  syringe  to  an  ex- 
tent not  desired  with  the  result  of  hyperinjection. 

This  fault  was  one  of  the  most  annoying  in  the  early 
days  of  such  injections  when  syringes  of  ordinary  pat- 
tern, such  as  the  Pravaz,  or  those  built  like  the  ordinary 
hypodermic,  were  used.  It  was  not  unusual  to  have  the 
paraffin  cool  in  the  needle  so  quickly  between  the  latter 
in  the  flame  of  an  alcohol  lamp  that  the  syringe  became 
unmanageable  and  broke  in  the  hands  of  the  operator. 
Since  that  time  new  and  more  useful  syringes  have  been 
introduced  by  various  operators  which  overcome  this 
difficulty,  yet  with  them,  too,  come  the  employment  of 
semisolid  paraffins  or  mixtures  thereof.  Yet,  as  some 
authors  insist  upon  using  paraffins  of  high  melting 
points,  it  may  be  well  to  rehearse  their  methods  of  over- 
coming this  annoying  intraneedle  solidification. 

Eckstein  surrounds  the  syringe  and  needle  shaft,  ex- 
cept the  tip  of  the  needle,  with  a  rubber  tubing,  as  shown 
in  Fig.  284,  to  act  as  an  insulator,  and  thus,  for  a  time 
at  least,  keep  the  preparation  liquid.  Before  filling  the 
syringe  he  heats  it  by  several  immersions  in  and  internal 


232      PLASTIC    AND    COSMETIC    SURGERY 


washings  of  hot  sterile  water.     To  prevent  the  paraffin 
from  setting  in  the  exposed  tip  of  the  needle  he  draws 


FIG.  284. — ECKSTEIN  METHOD  OF  INSULATING  NEEDLE  AND  SYRINGE. 

into  the  filled  syringe  a  few  drops  of  hot  water,  which 
are  injected  into  the  tissues,  causing  no  objection  to  the 

method. 

Paget  and  Harmon  Smith  warm 
the  needle  in  hot  sterilized  or  even 
boiling  water.  Previous  to  this 
Smith  cools  the  contents  of  the 
syringe  drawn  into  it  at  a  temper- 
ature of  120°  F.  by  immersing  the 
latter  in  a  bath  of  sterilized  water 
at  a  temperature  of  80°  F. 

From  the  above  it  will  be  noted 
that  Smith  advocates  using  the 
injections  in  semisolid  state  be- 
ing ejected  in  a  thin,  cylindrical 
thread.  A  syringe  of  special  con- 
struction, as  referred  to  later, 
is,  of  course,  required  for  such 
work. 

Quinlan  has  invented  a  so-called 
paraffin  heater,  as  shown  in  Fig. 
285,  in  which  the  paraffin  is  kept 
in  solution  by  the  syringe  being 
surrounded  by  a  continuous  flow 
of  hot  water.  A  plain  and  very 

objectionable  syringe  is  shown  in  the  illustration,  and 
while  the  preparation  in  the   syringe  is  thus  kept  in 


FIG.  285. — QUINLAN  PABAF- 
FIN  HEATER. 


HYDKOCAKBON  PEOTHBBES      233 

a  liquid  state  the  solidification  in  the  needle  is  not 
overcome. 

Downie  winds  fine  platinum  wire  about  the  needle 
through  which  he  passes  the  current  from  a  storage  bat- 
tery to  keep  the  needle  hot,  yet  such  an  arrangement  is 
obviously  difficult  of  manipulation,  and  when  paraffins 
of  high  melting  points  are  employed  it  is  quite  likely 
that  a  plug  is  formed  in  the  exposed  point  of  the  needle. 

Karewski  has  introduced  a  syringe  having  a  jacket 
through  which  hot  water  is  allowed  to  circulate,  while 
similar  instruments  have  been  originated  by  Pflugh  and 
De  Cazeneuve.  None  of  these  overcome  the  difficulty  in 
question. 

Viollet  went  even  further  by  inventing  a  syringe  sur- 
rounded with  a  coil  of  resistance  wire,  heated  by  an  elec- 
trical current,  and  Delangre,  Ewald,  and  Moszkowicz 
use  special  thermophorm  sleeves  over  the  syringe 
proper;  all,  however,  offering  the  same  objection  in  the 
exposure  of  a  part  of  the  needle  in  which  temperature  of 
the  liquid  must  necessarily  be  lowered,  or  be  low  enough 
to  cause  plugging,  the  very  fault  for  which  all  these 
modifications  have  incidentally  been  urged,  as  the  greater 
amount  of  paraffin  in  the  syringe  itself  is  as  a  rule  large 
enough  to  retain  sufficient  heat  to  permit  of  its  ejection, 
if  the  injection  is  made  as  expeditiously  as  possible. 

The  objection  of  the  setting  of  the  paraffin  in  the 
barrel  of  the  syringe  has  never  hampered  any  operator, 
the  difficulty  in  these  instances  having  been  entirely  due 
to  the  obstruction  offered  its  ejection  by  the  threadlike 
plug  obstructing  the  metal  cannula  before  it;  the  barrel, 
being  glass,  retains  its  temperature  more  readily  than 
the  thin  metal  needle,  hence  the  difficulty. 

That  all  prothetic  preparation  of  the  nature  in  hand 
should  be  placed  in  the  barrel  of  the  instrument  in  liquid 
form  is  essential,  in  that  the  syringe  is  thus  filled  to 
its  required  height  evenly,  and  devoid  of  air  spaces, 
yet  in  the  light  of  the  best  and  most  successful  results 


the  mass  should  be  allowed  to  cool  and  be  ejected  in 
^emisolid  state  from  a  specially  constructed  instrument, 
to  be  described  later. 

With  such  method  it  is  impossible  to  have  an  occlu- 
sion of  the  needle  at  any  time,  and  the  objection  of  sud- 
den outbursts  of  unknown  and  undesirable  quantities  of 
the  mass  is  entirely  overcome. 

15.  Absorption  or  Disintegration  of  the  Paraffin. — The  ques- 
tion of  the  ultimate  disposition  of  paraffin,  injected  sub- 
cutaneously  for  any  purpose,  has  been  an  extensive  one 
in  which  many  operators  have  taken  part. 

Gersuny  at  first  claimed  an  encapsulation  for  the  in- 
jected mass  of  vaselin,  which  he  states  was  not  taken  up 
by  the  lymphatics,  but  remained  in  situ  as  an  inert,  non- 
irritating  body.  Shortly  after  it  was  shown  that  the 
encapsulated  mass  soon  became  ramified  by  newly 
formed,  fine  bands  of  connective  tissue,  which  developed 
more  and  more  in  the  part  until  the  entire  mass  had  be- 
come displaced  by  this  tissue  with  an  eventual  consis- 
tency of  cartilage. 

Eckstein  claims  that  at  first  a  capsule  of  new  con- 
nective tissue  incloses  the  injected  mass  (Hart  paraffin) 
a  few  days  after  the  latter  is  injected,  which  can  be  eas- 
ily stripped  away  from  the  encapsulated  matter  several 
weeks  or  months  after,  showing  a  smooth  inner  wall, 
the  encysting  capsule  showing  a  decided  lack  of  blood 
vessels,  proving  histologically  its  relation  to  the  struc- 
ture of  cicatricial  formation. 

In  this  Eckstein  is  undoubtedly  mistaken.  He  ob- 
jects to  the  ultimate  replacement  with  connective  tissue 
for  the  vaselin  process  of  Gersuny,  when  in  reality  we 
have  begun  to  realize  that  such  result  will  follow  any 
hydrocarbon  subcutaneous  injection  unless  the  latter  be 
made  in  small  quantity  into  parts  of  the  body  which 
are  in  constant  motion. 

The  latter  is  shown  with  injections  of  paraffin  made 
into  or  about  the  nasolabial  fold.  The  tumor  is  so  small 


HYDROCARBON  PROTHESES      235 

as  to  be  hardly  felt  by  the  palpating  finger,  but  soon 
takes  on  larger  proportions,  evidencing  an  encapsulation 
of  some  extent  or  less  independent  of  the  encysted  mass. 
That  this  is  true  can  be  ascertained  by  incising  these 
little  hard  tumors  when  the  contents  can  be  readily 
pressed  out  or  evacuated,  the  mass  appearing  practi- 
cally as  injected  months  before. 

The  same  result  is  shown  by  Harmon  Smith,  who 
made  an  injection  of  paraffin  (110°  F.)  into  the  peri- 
toneal cavity  of  a  rabbit  which  was  killed  twenty-two 
days  later.  On  examination  no  sign  of  inflammation  of 
the  peritoneum  was  found — a  fact  that  seems  to  prove 
the  nontoxic  effect  of  paraffin — nor  were  there  evidences 
of  the  formation  of  adhesions.  The  mass  had  become 
rounded,  had  traveled  about  the  abdominal  cavity,  and 
was  found  lodged  between  the  liver  and  the  diaphragm. 

Comstock,  with  his  experiences  of  injections  of  par- 
affins at  high  melting  points,  found  that  the  harder  par- 
affins do  not  become  encysted,  but  become  a  part  of  the 
new  tissue,  which  belief  is  corroborated  by  Downie,  who 
introduced  paraffin  into  a  carcinomatous  breast.  Upon 
subsequent  amputation  and  microscopic  examination 
there  was  shown  an  intimate  connection  between  the 
ramified  site  of  the  injection  and  the  surrounding  tissue. 
The  same  results  have  been  noted  by  Jukuff. 

Smith  found  that,  in  trying  to  remove  an  injected 
mass  of  paraffin  several  months  after  introduction,  the 
greater  part  of  the  mass  had  become  so  thoroughly 
imbedded  in  the  meshes  of  the  newly  formed  connective 
tissue  that  it  was  practically  impossible  to  remove  it 
without  including  a  considerable  portion  of  the  con- 
nective tissue  as  well. 

Stein  claims  also  that  the  paraffin  is  absorbed,  little 
by  little,  as  it  is  replaced  by  the  new  connective  tissue, 
no  matter  what  the  melting  point  of  the  introduced  par- 
affin might  have  been.  The  mass  grows  smaller  to  a 
degree,  according  to  the  amount  injected;  finally,  at  the 


236     PLASTIC    AND    COSMETIC    SURGERY 

end  of  a  month  or  more,  the  entire  mass  is  replaced  by 
a  tissue  perceptibly  analogous  to  cartilage. 

Freeman,  like  Eckstein,  claims  that  encystment  of 
the  paraffin  occurs  soon  after  the  injection,  much  like 
that  following  a  bullet  or  other  foreign  body  in  the  tis- 
sues, but,  unlike  the  latter  author,  that  a  limited  amount 
of  the  connective  tissue  also  penetrates  the  mass,  which 
is  speedily  converted  into  a  solid  cartilagelike  body. 

Wendel  believes  entirely  in  the  encystment  theory, 
while  Hertel,  in  specimens  removed  twelve  to  fifteen 
months  after  injection  of  paraffin  with  a  melting  point 
of  100°  F.,  found  a  wall  of  round  cells  under  various 
states  of  inflammation  surrounding  the  masses  with 
fibers  of  connective  tissue  traversing  the  latter.  In  the 
various  histological  findings  he  argues  that  the  greater 
the  tissue  surface  exposed  to  the  injected  foreign  body 
the  greater  the  irritation,  and  the  larger  the  smooth  par- 
affin mass  the  less  the  reaction;  in  other  words,  small 
masses  of  the  injected  mass  cause  a  higher  rate  of  tissue 
formation,  while  the  larger  masses  have  a  tendency  to 
encystment  merely.  He  also  believes  that  the  harder 
paraffins  require  a  greater  length  of  time  to  become 
absorbed,  and  that  during  such  time  of  resorption  new 
connective-tissue  growth  is  established,  continuing  to 
the  time  of  its  complete  disappearance. 

Comstock,  after  thorough  and  extensive  investiga- 
tion with  the  injection  of  paraffins  of  various  melting 
points  made  at  varying  times  after  the  injection  of  such 
procedures,  concludes  definitely  that,  "  In  paraffin  we 
have  a  substance  that  will  fill  in  spaces  of  lost  tissue, 
and  not  remain  entirely  a  capsulated  foreign  body,  but 
become  a  bridgework,  and,  in  fact,  a  part  of  the  new 
tissue." 

Wenzel,  after  an  unsuccessful  attempt  to  overcome  a 
laparocele  by  the  injection  of  paraffin,  a  year  later  per- 
formed a  radical  operation  of  the  parts.  The  excised 
tissue  at  the  site  of  the  injection  showed  deposits  of  the 


HYDROCARBON  PROTHESES      237 

broken-up  mass  of  paraffin,  each  being  enveloped  by  a 
capsule  of  connective  tissue  without  any  signs  of  rami- 
fying bands,  and  hence  decided  against  the  belief  of  the 
resultant  tissue  formation. 

Eschweiler,  the  latest  authority  on  the  above  ques- 
tion, after  examining  microscopically  a  portion  of  paraf- 
fin-injected tissue  that  had  been  carried  "  in  situ  "  on  the 
bridge  of  the  nose  for  about  one  year,  concurs  absolutely 
with  the  connective-tissue  replacement  belief. 

From  the  foregoing  it  may  be  definitely  accepted  that 
while  there  may  be  an  encapuslation  or  encystment  of 
the  injected  mass,  be  it  what  it  may  so  long  as  it  belongs 
to  the  paraffin  group,  there  is  always  a  ramification  of  the 
mass  by  the  formation  of  the  strands  of  new  connective 
tissue  which  eventually  in  a  month  or  more,  according  to 
the  amount  of  the  mass,  develops  to  a  size  correspond- 
ing to  the  latter  or  even  beyond  the  size  of  the  latter,  as 
will  be  mentioned  later,  and  that  in  all  cases  the  paraffin 
is  ultimately  and  almost,  if  not  completely,  crowded  out 
of  the  area  occupied  by  the  injection,  and  that  its  disap- 
pearance is  accountable  to  absorption. 

This  absorption,  following  such  an  injection,  is  pro- 
ductive of  no  harm  to  the  human  economy,  and  the  new 
tissue  caused  to  be  formed  by  such  injection  truly  en- 
hances the  cosmetic  and  surgical  value  of  the  method 
inasmuch  as  an  encapsulated  mass  of  paraffin  is  liable 
to  displacement,  spreading,  and  irregularities,  should 
it  be  subjected  at  any  time  to  external  violence. 

Such  violence,  again,  would  lead  to  the  irritation 
and  inflammation  of  such  cyst  wall,  causing  an  undue 
crowding  upon  the  parts  injected  and  possible  gangrene 
of  that  part  of  the  wall  upon  which  such  pressure  was 
brought  to  bear,  leading  to  unsightly  attachment  and 
ultimate  contraction  of  the  skin  where  bound  down  by 
the  inflammation,  or  even  evacuation  by  the  absorption 
of  gangrenous  material  and  resultant  abscess. 

That  this  absorption  or  disintegration  of  paraffin  is 


of  no  consequence  may  be  proven  by  all  the  early  cases 
in  which  such  injections  were  used.  Gersuny's  first  case, 
having  been  done  May,  1899,  shows  no  diminution  of  the 
prothetic  site  at  the  end  of  two  years.  The  same  may 
be  said  of  the  hundreds  of  cases  done  by  other  operators. 

The  greater  question  in  the  mind  of  the  author  is 
what  will  be  the  ultimate  behavior  of  this  new  connective 
tissue. 

That  the  development  of  this  new  connective  tissue 
is  gradual  has  been  mentioned,  some  authors  claiming 
a  complete  replacement  of  the  mass  at  the  end  of  a 
month,  others  from  two  or  three  months.  Morton  says 
that  four  months'  time  is  required  before  the  mass  is, 
more  or  less,  completely  removed  and  replaced  by  organ- 
ized tissue.  The  author  believes,  however,  that  the 
length  of  time  necessary  for  this  replacement  not  only 
varies,  proportionately  with  the  amount  of  paraffin  in- 
jected, but  that  it  differs  in  each  case,  and  markedly  with 
some  patients  in  which  the  growth  or  developments  of 
the  new  tissue  did  not  cease  for  months  and  even  a  year 
after  such  injection.  This  corresponds  truly  to  a  hyper- 
plasia,  and  will  be  considered  later. 

Time  alone  will  show  the  ultimate  behavior  of  this 
new  tissue,  and  while  it  is  reasonable  to  argue  that  this 
newly  organized  tissue  could  cause  no  untoward  results, 
it  must  be  determined  whether  this  tissue  will  not  un- 
dergo atrophy  and  contract,  or  become  susceptible  to 
other  changes  in  time.  It  is  a  new  tissue  practically,  and 
as  yet  we  know  nothing  of  its  idiosyncrasies,  although 
its  histological  nature  is  determined. 

We  do  not  know  that  irritations,  such  as  surgical  in- 
terference, will  cause  it  to  take  on  new  growth,  as  evi- 
denced by  the  attempts  of  extirpation  of  unaccountable 
overcorrections  obtained  with  injections  made  early  in 
the  time  of  the  employment  of  the  Gersuny  method,  in 
which  the  parts  practically  grew  back  to  their  former 
size  or  became  even  larger.  This  may  be  accounted  for 


239 

by  the  fact  that  most,  if  not  all,  of  the  connective  tissue 
was  not  removed  or  points  to  an  active  nucleus  or  sev- 
eral such  centers  which  were  not  destroyed. 

That  the  growth  is  not  limited  by  the  size  of  the  mass 
injected  is  the  author's  belief;  in  other  words,  the  re- 
placement of  the  new  tissue  is  not  proportionate  to  the 
injection,  but  that  other  forces,  such  as  adjacent  tissue 
pressure  and  presence  and  outer  influences,  as,  for  in- 
stance, the  daily  massage  of  the  parts  with  the  hands, 
have  much  to  do  with  the  final  amount  of  tissue  caused 
to  be  developed  by  the  initial  stimulus  of  the  injection. 
Nothing  further  or  definite,  however,  has  been  written 
on  this  supposition. 

16.  The  Difficulty  of  Procuring  Paraffin  with  the  Proper  Melt- 
ing Point. — This  should  not  prove  an  objection  to  the 
method,  since  operators  can  procure  pure  and  sterilized 
paraffins  of  the  various  melting  points  from  any  reliable 
chemical  house. 

What  the  operator  should  determine  first  of  all  is  the 
kind  of  paraffin  he  intends  to  use  for  subcutaneous  injec- 
tion. 

The  selection  of  paraffin  of  a  certain  melting  point 
should  be  influenced  by  what  he  has  read  on  the  subject, 
as  given  by  authorities  of  wide  experience. 

A  few  cases  do  not  suffice  from  which  to  draw  con- 
clusions ;  it  is  only  from  a  great  number  of  similar  oper- 
ations that  a  definite  form  or  preparation  of  paraffin  can 
be  decided  on. 

From  the  following  authorities  is  shown  a  variance 
in  the  melting  points  of  the  preparations  used,  but  by 
a  glance  it  may  be  noted  that  the  first  division  of  men, 
from  numbers  1  to  10  inclusive,  use  paraffins  of  melting 
points  very  near  to  each  other;  the  latter  group,  from 
11  to  13  inclusive,  employ  those  of  the  higher  melting 
points. 

The  former  group  may,  therefore,  be  said  to  utilize 
the  paraffins  of  lower  melting  points. 


240     PLASTIC    AND    COSMETIC    SURGERY 


GROUP  I 

1.  Gersuny 36-40°  C.      97-104°  F. 

2.  Moskowicz 36-40°  C.      97-104°  F. 

3.  Parker 102°  F. 

4.  Freeman 40°  C.    104°   F. 

5.  A.  E.  Comstock 107°  F. 

6.  Walker  Downie 104-108°  F. 

7.  A.  W.  Morton 109°   F. 

8.  Harmon  Smith 110°  F. 

9.  Stephen  Paget 108-115°  F. 

10.  Pfannenstiel 115°  F. 

GROUP  II 

11.  Brcecksert 56°  C.  133°  F. 

12.  Eckstein 56-58°  C.      133-136°  F. 

13.  Karewski..  .   57-60°  C.      134-140°  F. 


From  a  glance  of  the  first  group  the  variance  of  the 
temperature  of  melting  points  is  not  a  great  one,  prac- 
tically lying  between  102°  and  115°  approximately. 
When  we  consider  the  actual  difference  in  the  employ- 
ing practicability  and  the  effect  upon  the  tissue  there 
is  practically  little,  if  any,  difference.  The  only  differ- 
ence between  these  authorities  is  that  some  employ  their 
preparation  in  liquefied  form,  through  the  application 
of  heat,  while  the  others  employ  it  in  the  cold  or  semi- 
solid  form.  The  choice  of  such  method,  from  what  has 
already  been  said,  should  unreservedly  be  the  employ- 
ment of  a  paraffin  in  the  cold  or  semisolid  form  at  a 
mean  temperature  of  about  110°  F. 

This  choice  would  fall  upon  any  one  of  the  paraffins 
used  by  the  authorities  given  in  Group  I. 

The  objections  to  the  "  Hart  paraffins  "  of  melting 
points  given  in  Group  II  have  been  sufficiently  shown  in 
preceding  paragraphs,  although  a  few  pointed  objec- 
tions from  the  various  surgeons  may  not  be  out  of  place 
here  to  offset  the  claims  and  advocacies  of  those  employ- 


HYDROCARBON  PROTHESES      241 

ing  the  preparation  in  liquid  form  at  higher  tempera- 
tures than  110°  F. 

Paget  says :  "  I  am  absolutely  sure  now  that  Eck- 
stein's paraffin  is  without  any  real  advantage.  It  is  very 
difficult  to  handle;  it  sets  very  rapidly;  it  causes  a  great 
deal  of  swelling  and  some  inflammation,  and  may  even 
produce  some  discoloration  of  the  skin,  and  it  yields  no 
better  results  than  does  Pfannenstiel's  paraffin,  which 
melts  at  110°  F." 

Again  he  says :  "  The  best  paraffin  is  that  which  has  a 
melting  point  somewhere  between  108°  and  115°  F. 
When  the  paraffin  has  to  stand  heavy  and  immediate 
pressure,  the  higher  melting  point  is  preferable." 

He  had  up  to  the  date  of  the  latter  extract  operated 
upon  forty-three  cases  of  deformed  noses  and  "  in  no 
case  was  there  embolism,  sloughing  of  the  skin,  or  wan- 
dering of  paraffin." 

Paget,  however,  employs  the  paraffin  in  liquefied 
form,  and  allows  cold  water  to  trickle  over  the  nose 
while  the  injection  is  molded  into  form.  Of  this  later. 

Comstock  says,  "  Paraffin  must  be  used  where  it  will 
be  at  all  time  above  the  body  temperature,"  and  fur- 
ther that,  "  in  selecting  the  melting  temperature  for  sur- 
gical uses,  it  should  be  that  from  106°  to  107°  F.,  the 
best  for  use  in  subcutaneous  injections,  for  the  reason 
that  it  gives  a  substance  firm  enough  to  hold  very  well 
its  form,  especially  when  confined  by  the  surrounding 
tissue,  and  at  the  same  time  with  a  melting  point  out  of 
the  reach  of  the  system  at  all  times." 

From  this  we  are  given  to  understand  that  he  uses 
his  preparation  in  cold  form  entirely  when  injecting,  but 
of  the  melting  point  mentioned. 

The  author  can  see  no  advantage  in  using  any  paraf- 
fins of  low  temperature  melting  points  in  liquid  form. 
Here  is  the  very  factor  of  causing  embolism  reintroduced. 
Surely  a  liquid  of  any  kind  injected  into  a  blood  vessel 
will  give  cause  for  trouble,  even  if  the  temperature  of 

17 


242      PLASTIC    AND    COSMETIC    SURGERY 

the  setting  of  such  a  paraffin  be  high  or  low.  The  em- 
ployment of  the  paraffins  of  a  melting  point  above  120° 
F.  hi  cold  form  is  difficult,  if  not  impossible,  even  with 
the  latest  pattern  of  screw  syringe  which  is  quite  true, 
but  there  is  no  need  of  using  such  paraffin  nor  any  lique- 
fied paraffin,  since  any  such  preparation  of  about  the  melt- 
ing point  of  110°  F.  will  serve  every  purpose  overcom- 
ing all  the  objections  of  the  advocates  of  those  using  any 
other. 

If  a  vessel  be  injected  and  filled  with  any  paraffin 
preparation  there  is  danger  of  phlebitis  and  thrombosis ; 
the  only  possible  way  to  overcome  it  is  not  to  puncture 
the  vessel. 

While  a  preparation  injected  cold  can  be  more  easily 
governed  from  without  by  digital  pressure  or  guidance, 
what  can  be  said  for  a  hot  seething  preparation  intro- 
duced under  great  pressure? 

Furthermore,  when  paraffin  is  injected  in  liquid 
form,  especially  when  so  rendered  by  a  temperature 
necessarily  even  higher  than  the  actual  melting  point, 
there  is  danger  of  searing  the  entire  site  intended  for 
injection — a  condition  inducive  to  no  good  and  a  burning 
of  the  skin  where  the  necessary  superheated  needle  en- 
ters it,  causing  a  punctate  scar,  more  or  less  painful 
during  the  time  required  to  heal  the  wound. 

With  the  later  knowledge  that  small  amounts  should 
be  injected,  and  that  such  injections  should  be  repeated, 
it  being  known  that  such  method  facilitates  the  produc- 
tion of  new  connective  tissue,  may  we  not  draw  the  con- 
clusion that  the  result  obtained  by  the  injection  depends 
not  upon  the  injection  per  se,  but  the  resultant  of  that 
injection — namely,  tissue  production,  and  that  this  tissue 
production  is  the  outcome  of  a  stimulus  in  the  form  of 
that  injection? 

There  has  not  appeared  an  authority  who  has 
claimed  otherwise  for  injections  of  paraffin  hot  or  cold, 
while  it  is  true  that  the  use  of  liquefied  paraffins  at  high 


243 

temperatures  have  caused  all  sorts  of  untoward  results, 
while  those  of  lower  melting  points  in  similar  form  have 
not  escaped  objections. 

The  author  has  used  the  cold-injection  method  in 
over  three  hundred  nose  cases  without  a  single  case  of 
sloughing,  embolism,  or  death,  and  in  no  case  was  there 
secondary  diffusion  or  hyperinjection.  The  only  fault 
has  been  the  desire  on  the  part  of  the  patient  to  be  fin- 
ished too  quickly,  which  usually  leads  to  a  result  not  as 
satisfactory  as  when  the  injections  are  made  sufficiently 
far  enough  apart  to  allow  the  formation  of  organized 
tissue  at  the  site  of  injection. 

Gersuny's  preparation  of  paraffin,  particularly  use- 
ful for  the  cold-injection  method,  is  made  as  follows:  A 
certain  amount  of  cold  paraffin,  melting  at  about  120°  F., 
and  white  cosmolin  or  vaselin,  melting  at  about  100°  F., 
are  mixed  by  being  heated  to  liquefaction.  The  bulb 
of  a  clinical  thermometer  is  then  coated  with  the  cooled 
mixture  of  paraffin,  which  is  then  placed  into  a  hot-water 
bath,  the  temperature  of  which  is  gradually  raised  until 
the  paraffin  melts  and  floats  upon  the  surface  of  the 
water.  The  water  is  then  allowed  to  cool  and  its  tem- 
perature noted  just  as  the  oil-like  liquid  paraffin  begins 
to  look  opaque,  which  marks  the  melting-temperature 
point  of  the  mixture. 

Should  this  be  found  to  be  too  high  more  vaselin  is 
added,  or  vice  versa,  until  the  desired  quantity  of  both 
is  known. 

This  method  of  preparation  is,  however,  a  tedious 
and  awkward  one,  and  can  be  readily  improved  upon  by 
mixing  certain  known  quantities  of  the  one  with  the 
other  after  the  first  experiment. 

The  author  recommends  the  following  formula  for 
the  preparation  of  a  mixed  paraffin,  which  he  has  found 
serviceable  and  satisfactory  for  use  with  cold-process 
injections  and  employed  by  him  for  the  last  four 
years. 


244      PLASTIC    AND    COSMETIC    SURGERY 

I£  Paraffin    (plate,   sterile) r>i j ; 

Vaselin  alba  (sterile) ,}ij. 

The  two  are  placed  into  a  porcelain  receptacle  and 
melted  in  a  hot-water  bath  to  the  boiling  point,  then 
thoroughly  mixed  by  stirring  with  a  glass  rod  and 
poured  into  test  tubes  of  appropriate  size  and  allowed 
to  cool.  Each  tube  is  sealed  properly  with  a  close-fitting 
rubber  cork,  which  may  be  coated  with  a  liquid  paraffin 
without,  including  the  neck  of  the  tube,  and  put  away 
for  later  use. 

Since  1905  the  author  has  used  an  electrothermic 
heating  device  in  which  the  paraffin  mixture  is  prepared. 


FIG.  286. — AUTHOR'S  ELECTROTHERMIC  PARAFFIN  HEATER. 

The  apparatus  is  made  up  of  a  metal  pot  set  into  a  re- 
sistance coil,  and  is  shown  in  Fig.  286. 

This  instrument  overcomes  the  complications  of  the 
water  bath  and  burning  or  browning  of  the  paraffin  mix- 
ture, so  commonly  found  with  ordinary  methods,  the 
temperature  of  the  resistance  coil  within  the  heating 
chamber  being  controlled  by  a  small  rheostat  at  will. 


HYDROCARBON  PROTHESES      245 

Before  using,  the  contents  of  each  test  tube  thus  pre- 
pared are  reheated  to  sterilization  and  poured  into  the 
barrel  of  the  syringe  to  two  thirds  of  its  length,  the 
piston  introduced  and  screwed  down  into  position;  the 
syringe  being  placed  to  one  side  until  its  contents  have 
been  cooled,  or  the  entire  instrument  is  immersed  in 
sterilized  water  at  about  70°  F.  until  the  paraffin  mix- 
ture has  set  or  becomes  uniform  in  consistency,  which 
takes  about  five  minutes. 

Upon  screwing  down  the  piston  the  mass  will  be 
found  to  issue  from  the  needle  as  a  white,  cylindrical 
thread,  and  is  ready  for  use  in  this  form. 

Harmon  Smith  has  had  such  a  paraffin  prepared 
which  has  a  melting  point  of  110°  F.  This  can  be  pur- 
chased in  the  market  in  sterile  sealed  tubes  ready  for 
use.  The  contents  of  these  tubes  should,  however,  be 
resterilized  at  the  time  of  employment. 

The  same  author  prepares  this  paraffin  of  110°  F. 
melting  point  by  mixing  sufficient  petroleum  jelly  (evi- 
dently white  vaselin)  with  the  commercial  paraffin  melt- 
ing at  about  120°  F.  to  bring  the  melting  point  down  to 
110°  F.  He  claims  that  making  such  a  mixture  is  a 
difficult  matter,  since  a  plate  of  paraffin  will  have  vari- 
ous melting  points,  one  corner  melting  at  120°  and  the 
opposite  as  high  as  140°  F.  He  advises  having  the  mix- 
ture accurately  prepared  in  large  quantities  and  dis- 
pensing it  in  test  tubes  of  one-half  ounce  capacity,  as 
now  found  on  the  market.  The  mixture  is  poured  in  hot 
liquid  form  into  these  test  tubes,  which  are  then  sealed 
with  wax  and  placed  on  a  sand  bath,  whose  temperature 
is  raised  to  300°  F.  to  insure  sterilization. 

The  latter  author  has  devised  a  neat  paraffin  heater, 
shown  in  Fig.  287. 

Of  this  he  says :  "  To  insure  still  further  the  steril- 
ization of  the  paraffin,  I  have  devised  a  tin  (nickle- 
plated)  receptacle  supported  on  an  attached  tripod, 
which  raises  the  bottom  an  inch  from  any  plane  surface 


246      PLASTIC    AND    COSMETIC    SURGERY 

on  which  it  is  placed,  and  is  closed  with  a  detachable  lid. 
This  arrangement  prevents  the  paraffin  from  burning 
or  browning.  Into  this  I  pour  the  paraffin  from  the 
test  tube,  after  melting,  and  place  this  receptacle  into  a 


FIG.  287. — SMITH  PARAFFIN  HEATER. 

sterilizer,  or  any  ordinary  boiler — surround  it  almost 
entirely  with  water  and  then  boil.  After  I  have  boiled 
it  for  a  few  minutes  I  remove  the  receptacle  and  per- 
mit it  to  cool  until  the  paraffin  therein  is  about  120°  F. 
I  then  draw  it  up  into  the  syringe,  which  has  been  ster- 
ilized in  the  same  boiler  with  the  paraffin.  When  suffi- 
cient is  withdrawn,  I  evacuate  the  air  bubbles  from  the 
syringe  by  pressing  the  piston  upward  and  run  my  set 
screw  into  place.  Some  two  or  three  minutes  are  now 
allowed  for  the  paraffin  to  assume  equal  consistency 
throughout  and  to  cool  down  to  a  semisolid  state. 
When  the  paraffin  reaches  this  consistency  it  may  be 
kept  many  hours  ready  for  use,  at  the  temperature  of  the 
room,  if  only  the  precaution  to  warm  the  needle  is  taken 
each  time  before  attempting  the  injection." 

17.  Hypersensitiveness  of  the  Skin. — A  permanent  hyper- 
sensitiveness  of  the  skin  over  the  site  of  a  subcutaneous 
paraffin  injection  has  never  been  definitely  shown.  While 
it  is  true  there  is  some  pain  and  feeling  of  stress  and  full- 


HYDROCARBON  PROTHESES      247 

ness  over  and  about  such  area,  immediately  after  the 
operation,  this  has  subsided  in  about  twenty-four  hours 
in  the  average  case,  except  in  those  where  a  very  hot 
liquid  paraffin  and  of  large  amount  has  been  injected, 
when  several  days  are  required  to  overcome  these  symp- 
toms. 

Smith  claims  a  numbness  over  the  site  of  the  injected 
area  which  soon  passes  away,  but  this  is  perhaps  more  a 
feeling  of  fullness  rather  than  one  of  anesthesia. 

The  author  has  observed,  however,  in  several  cases  a 
period  of  extreme  discomfort,  fullness  and  cephalalgia  in 
cases  of  subcutaneous  injections  about  the  root  of  the 
nose.  Peculiarly  these  attacks  appear  only  after  the 
filling  has  become  organized ;  that  is,  after  the  connective 
tissue  has  displaced  the  paraffin.  The  secondary  tumor 
in  such  cases  appears  to  be  slightly  larger  superiorly 
than  the  original  size  at  the  time  of  injection. 

The  irregularity  of  these  attacks,  with  edema  of  the 
forehead  and  slight  puffing  of  the  upper  eyelids,  points 
to  a  disturbance  of  the  circulation  and  is  undoubtedly 
due  to  pressure  on  the  angular  vessels,  and  the  venous 
arch  across  the  root  of  the  nose.  The  symptoms  usually 
appear  in  the  early  morning  and  moderate  toward  night, 
reappearing  again  the  next  morning  or  not  again  until 
the  next  attack,  which  may  be  expected  at  any  time. 

This  condition  of  affairs  is  an  unfortunate  one,  since 
we  cannot  look  to  the  avoidance  of  the  trouble  nor  fore- 
see it  at  the  time  of  operation.  In  one  case  the  symptoms 
did  not  develop  until  nearly  two  years  after  the  injection 
was  made  and  became  so  troublesome  that  the  only  relief 
had  was  by  opening  the  skin  of  the  nose  laterally  and 
excising  as  much  as  seemed  necessary  of  the  newly 
formed  connective  tissue  with  a  fine  pair  of  curved  scis- 
sors. None  of  the  injected  matter  was  discovered  except 
two  fine  scalelike  disks  of  glistening  paraffin  of  a  diam- 
eter of  one  sixteenth  inch.  These  were  evidently  all  that 
remained  of  the  injected  mass,  and  were  undoubtedly  held 


248      PLASTIC   AND    COSMETIC    SUBOEEY 

in  the  innermost  meshes  of  the  new  tissue.  Immediate 
relief  followed  the  operation,  but  no  appreciable  differ- 
ence in  the  size  of  the  tumor  could  be  noticed. 

Cold  applications  or  ice  cloths  relieve  the  temporary 
pain  following  an  injection  of  paraffin,  but  in  most  cases 
this  is  rarely  necessary  except  in  extremely  nervous  and 
expectant  patients. 

On  the  whole  the  author  believes  the  secondary  neu- 
roses and  circulatory  difficulties  are  now  practically  over- 
come by  the  more  conservative  use  of  the  matter  to  be 
injected,  coupled  with  a  repetition  of  the  injection  of 
smaller  amounts  at  each  sitting  and  not  repeating  the 
same  until  the  first  has  become  organized. 

18.  Redness  of  the  Skin. — Redness  of  the  skin  following 
an  injection  of  the  nature  under  consideration  was  one 
of  the  early  objections  made  by  various  operators. 

That  redness,  more  or  less  permanent,  has  been  found 
in  many  cases  in  which  these  injections  were  made  is 
true,  but  such  redness  was  found  particularly  when  the 
injections  were  those  of  liquid  paraffin  of  high  melting 
points  and  in  which  the  operator  was  overzealous  in 
bringing  about  an  absolute  correction  of  a  deformity, 
with  the  result  that  when  the  paraffin  had  been  molded 
and  set,  it  was  generally  pinched  or  shaped  up  or  out- 
ward, thus  causing  a  great  deal  of  pressure  upon  the  cir- 
culatory vessels  of  *the  skin. 

The  redness  in  such  cases  did  not  appear  until  sev- 
eral days  after  the  operation,  becoming  worse  gradually 
instead  of  better  even  in  spite  of  the  efforts  to  reduce  it 
by  external  applications.  Not  unusually,  in  the  perma- 
nent cases,  distended  capillaries  can  be  seen  in  the  skin 
resembling  the  condition  in  acne  rosacea  chronica,  espe- 
cially when  the  injection  had  been  made  to  correct  a 
saddle  nose. 

Smith  says :  "  Redness  is  present  in  a  good  many 
cases.  I  have  seen  a  case  in  which  the  redness  lasted  over 
a  year,  but  it  gradually  disappeared.  There  seems  to 


HYDROCARBON  PBOTHESES      249 

be  a  tendency  on  the  part  of  nature  to  take  care  of  a  for- 
eign body,  and  I  think  the  reenforcement  of  connective 
tissue  that  grows  into  this  mass  requires  an  increased 
blood  supply,  and  later,  when  the  blood  supply  is  no 
longer  necessary,  the  redness  will  disappear." 

The  latter  is  true  where  the  hyperemia  is  either  acute 
or  subacute,  but  in  chronic  cases  where  the  capillaries 
have  become  distended  and  show  plainly  there  is  little  to 
be  hoped  through  the  effort  of  nature. 

Eckstein,  the  advocate  of  "  Hart-paraffin  "  method  of 
high  melting  point,  states  that  a  redness  of  the  parts  de- 
velops a  few  days  after  the  injection  that  disappears 
after  a  time,  but  that  this  redness  is  more  marked  and  of 
longer  duration  when  the  injections  are  made  intracuta- 
neous  instead  of  subcutaneous. 

These  injections  should  be  made  subcutaneous  in  all 
cases,  and  there  is  no  excuse  for  deviating  from  this 
method. 

With  the  use  of  semisolid  and  cold  paraffin  mixtures, 
as  heretofore  advocated,  redness  rarely  if  ever  follows 
the  injection  unless  undue  pressure  has  been  made,  in 
which  case  necrosis  is  more  liable  to  follow  unless  the 
adjacent  tissue  will  gradually  allow  the  mass  to  become 
relieved  by  a  change  in  form  and  position. 

Such  subsequent  hyperemias  are  not  now  as  common 
as  when  the  injections  were  at  first  attempted,  and  the 
author  may  say  freely  that  they  never  occur  when  the 
proper  method  and  material  is  used. 

Paget  says :  "  In  a  few  cases — but  only  in  a  few — 
some  reddening  of  the  skin  has  followed  the  injection, 
and  in  a  few  this  has  been  very  slow  to  fade. 

"  The  few  referred  to  are  of  a  record  of  twenty-two 
nasal  cases,  but  no  data  is  given  whether  the  operator 
used  paraffin  of  high  or  low  melting  points.  F.  Connell 
found  that  redness  in  that  case  continued  for  a  year, 
diminishing  very  little  in  that  time.  It  appeared  on  the 
second  time  after  the  operation  for  a  correction  of  a 


250      PLASTIC    AND    COSMETIC    SURGERY 

saddle  nose,  and  remained  stationary  for  about  one 
month.  Twenty  drops  of  paraffin  were  injected.  It  very 
gradually  increased,  so  gradually,  in  fact,  that  there  is 
still  a  distinct  reddened  area  over  the  bridge  of  the  nose. 
On  pressure  this  redness  will  disappear,  but  returns  im- 
mediately after  the  removal  of  the  pressure.  A  few 
dilated  and  tortuous  capillaries  course  their  way  over 
the  area.  The  condition  is  still  present  fourteen  months 
after  the  injection. 

"  There  has  been  practically  no  change  or  decrease 
in  the  redness  during  the  last  six  or  seven  months,  it  is 
not  as  marked  as  it  was  during  the  first  few  months, 
but  still  requires  the  profuse  application  of  face  powder 
in  order  to  prevent  her  nose  from  being  conspicuously 
red." 

The  above  case  has  been  cited  because  it  is  typical 
of  such  condition,  and  while  the  amount  as  stated  was 
quite  small,  one  is  almost  nonplused  for  an  explanation 
of  the  result,  yet  it  undoubtedly  must  have  been  due 
to  a  close  attachment  of  the  skin  to  the  underlying  struc- 
tures, necessitating  pressure,  which  is  known  to  cause  it. 

However,  it  is  possible  to  have  such  redness  develop 
weeks  or  months  after  the  injections  are  made.  In  such 
cases  it  is  not  due  to  the  primary  pressure  of  the  injec- 
tion, but  to  that  of  the  newly  developed  tissue  which 
has  taken  its  place,  but  which  is  slightly  overdeveloped 
for  the  same  unaccountable  reason  already  referred  to. 

Almost  every  surgeon  who  has  used  this  method  of 
restoring  the  contour  of  parts  of  the  face  has  observed 
redness,  more  or  less  permanent,  follow  the  method  used, 
but  in  most  cases  liquid  paraffin  of  high  melting  points 
had  been  forced  into  the  tissues  at  great  pressure. 

In  one  case,  that  of  a  southern  operator,  the  entire 
tip  of  the  nose  had  become  injected  by  primary  diffusion 
or  direct  filling. 

It  became  inflamed  immediately  after,  and  some  weeks 
later,  when  the  swelling  had  subsided,  the  lobule  was 


HYDROCARBON  PROTHESES      251 

found  to  be  very  hard,  tense,  and  extremely  red.  Two 
years  after  the  author  saw  this  case,  and  the  tip  of  the 
nose  still  appeared  like  a  red  cherry  with  numerous 
capillaries  showing  over  its  area,  while  the  rest  of  the 
nose,  although  much  broadened  by  secondary  displace- 
ment of  the  paraffin,  was  natural  in  color. 

This  proves  that  as  the  pressure  was  relieved  by 
absorption  and  displacement,  the  tissue  took  on  a  normal 
appearance,  whereas  in  the  lobule  of  the  nose,  where 
there  was  no  relief  from  the  pressure,  nature  could  do 
nothing  to  relieve  the  inevitable  result. 

In  cases  where  the  redness  is  suspected  it  may  not  be 
too  late,  a  day  or  two  after  the  injection,  to  remold  the 
mass  into  such  form  as  to  relieve  the  acute  tension. 

If  the  redness  develops  early,  cold  applications  of  an 
antiseptic  nature  or  ice  cloths  can  be  used  to  advantage. 
Antiphlogistin  or  other  similar  preparations  applied  ex- 
ternally give  good  results. 

Later  ichthyol,  twenty-five-per-cent  solution,  may  be 
applied;  acetate  of  alumen  in  saturated  solution  seems 
to  do  well.  Some  operators  apply  hydrogen  peroxid, 
but  it  gives  only  temporary  benefit.  When  the  capil- 
laries have  become  distended  and  the  redness  is  prac- 
tically chronic  the  vessels  should  be  destroyed  with  a  fine 
electric  needle,  using  about  20  milliamperes — direct  cur- 
rent. 

Sometimes  when  the  redness  is  acute  and  seems  to 
persist  depletion  of  the  part  does  some  good.  This  is 
done  by  nicking  the  skin  here  and  there  with  a  fine  bis- 
toury and  allowing  the  part  to  bleed  freely.  Care  should 
be  taken  not  to  puncture  the  skin  too  deeply,  so  as  not 
to  allow  the  injected  mass  to  escape. 

In  some  cases  it  is  allowable  to  open  the  filled  cavity 
early  and  remove  enough  of  the  filling  to  overcome  the 
difficulty,  injecting  later,  after  the  filling  has  become  or- 
ganized, to  make  up  the  deficiency. 

When  the  redness  is  secondary — that  is,  when  it  de- 


252      PLASTIC    AND    COSMETIC    SUKGERY 

velops  after  the  connective  tissue  has  replaced  the  paraf- 
fin—  it  is  best  to  open  up  the  part  and  excise  enough  of 
the  tissue  to  overcome  the  pressure. 

In  a  case  where  the  author  injected  for  a  deep  fur- 
row in  the  forehead  with  a  cold  semisolid  paraffin  mix- 
ture, a  secondary  redness  developed  three  months  after 
the  injection  had  been  made,  no  redness  having  been 
noticed  in  the  meantime.  There  was  more  or  less  swell- 
ing for  two  or  three  weeks,  undoubtedly  due  to  pressure 
phlebitis,  which  eventually  subsided. 

The  redness  in  this  case  was  only  reduced  by  an  ex- 
cision of  the  tissue  causing  the  trouble.  The  result  was 
satisfactory. 

19.  Secondary  Diffusion  of  the  Injected  Mass. — This  is  a 
condition  that  no  operator  can  foretell,  although  it  might 
be  caused  by  a  primary  diffusion  due  to  hyperinjection 
of  so  small  an  extent  that  it  escaped  the  surgeon's  atten- 
tion at  the  time. 

Again,  a  site  injected  may  at  the  time  of  operation 
present  all  the  indications  of  a  satisfactory  result — that 
is,  the  tissues  at  the  place  of  operation  and  its  immediate 
vicinity  appear  perfectly  loose  and  elastic;  the  injection 
being  made  easily  and  the  contour  of  the  defect  being 
remedied  either  partially  or  entirely  as  the  operator  may 
dsire;  there  being  no  mechanical  anemia  post-operatio, 
and  no  decided  effort  on  the  part  of  the  tissues  to  cause 
primary  elimination  after  the  withdrawal  of  the  needle; 
yet  it  is  possible  that,  by  such  an  injection,  sufficient 
pressure  may  be  caused  upon  some  of  the  blood  vessels 
within  the  limitations  of  the  injection  as  to  cause  a  de- 
cided reaction  a  few  hours  after  the  operation,  as  evi- 
denced by  a  swelling,  too  great  for  the  disturbance  occa- 
sioned, and  associated  with  all  the  signs  of  a  fairly  active 
inflammation. 

It  is  possible  that  such  a  reaction  may  cause  a  dis- 
placement or  diffusion,  post-primary,  of  the  mass  in- 
jected, especially  if  the  mass  be  merely  vaselin  or  a  mix- 


HYDROCARBON  PROTHESES      253 

ture  of  vaseHn  and  paraffin  at  a  melting  point  too  low 
for  the  purpose.  Nevertheless,  it  is  practically  impossi- 
ble to  foresee  such  result  and  the  operator  can  only  use 
the  same  care  as  with  any  or  all  such  injections. 

It  is  possible,  when  the  reaction  is  too  marked,  to 
mitigate,  to  a  great  extent,  this  diffusion  of  the  injected 
mass,  by  using  such  methods  as  reduce  the  inflammatory 
symptoms. 

As  a  rule,  these  cases  exhibit  considerable  ecchymosis 
after  this  active  reaction  has  subsided,  lasting  from  one 
to  two  weeks. 

Secondary  diffusion,  as  the  author  uses  the  term,  sig- 
nifies an  extension  of  the  injected  mass  beyond  the  in- 
tended area.  This  may  occur  in  two  or  three  weeks  or 
be  proportionate  to  the  activity  of  the  production  of 
fibrous  connective  tissue  that  is  supplanting  the  mass. 

Leonard  Hill  has  reported  a  case  in  which  he  injected 
vaselin  to  correct  a  saddle  nose  for  aesthetic  or  cosmetic 
reasons.  The  result  was  very  satisfactory  to  both  oper- 
ator and  patient,  and  continued  so  for  nearly  twelve 
months,  when  secondary  diffusion  of  the  mass  began  to 
be  noticeable.  Eventually  the  diffusion  became  so  great 
in  the  upper  eyelids  as  to  close  both  eyes  completely. 

The  worst  case  of  such  secondary  diffusion  the  author 
has  ever  heard  of  or  seen  came  to  his  attention  early  this 
year.  The  patient  had  been  subjected  to  a  subcutaneous 
injection  of  oils  for  the  cosmetic  correction  of  an  abnor- 
mal deepening  of  the  inner  clavicular  notch.  The  in- 
jected mixture,  as  far  as  the  author  could  learn,  was 
made  up  of  sweet  almond,  peanut,  and  olive  oils  with 
two  others  that  had  been  forgotten.  Her  physician  had 
made  two  injections  several  days  apart  with  a  satisfac- 
tory result.  The  reaction  was  trifling  and  the  parts  re- 
turned to  the  normal  in  two  weeks. 

Five  months  later  the  part  injected  became  tender  to 
the  touch  and  began  to  enlarge  daily.  With  the  increase 
in  size  a  gradual  inflammation  involved  the  whole  lower 


254      PLASTIC   AND    COSMETIC    SURGERY 

region  of  the  anterior  region  about  the  root  of  the  neck. 
Various  applications  were  made  to  the  part  to  reduce  the 
inflammation,  but  at  the  end  of  ten  days  a  region  of  skin 
that  had  indicated  the  pointing  of  an  abscess  burst,  al- 
lowing the  escape  of  about  eight  ounces  of  pus.  Under 
the  most  careful  surgical  attention  this  discharge  con- 
tinued for  about  three  months,  until  under  the  influence 
of  gauze  packing  the  wound  was  made  to  heal  from  the 
bottom,  leaving  an  ugly  irregular  scar  at  the  site  of  the 
opening.  With  the  healing  of  this  fistular  wound,  how- 
ever, the  size  of  the  tumor  did  not  diminish  whatever, 
but  continued  to  grow  until,  at  the  present  time,  one  and 
one  half  years  after  the  injections  had  been  made,  the  size 
of  this  peculiar  hyperplastic  growth  of  ovate  form  meas- 
ures nearly  five  inches  across  its  horizontal  diameter  and 
three  and  one  half  inches  through  the  vertical.  It  is 
closely  adherent  to  the  overlying  thickened  skin,  which 
has  undergone  a  yellow  pigmentary  change  to  be  consid- 
ered in  the  next  text  subdivision.  The  tumor  is  hard, 
painless,  and  freely  movable  beyond  the  limitation  of  its 
skin  atttachment  and  rests  upon  the  sternal  thirds  of  the 
clavicles,  extending  upward  and  forward  with  evidences 
of  tra3tion  on  the  whole  anterio  skin  of  the  neck.  Laryn- 
goscopy  discloses  nothing  abnormal.  The  deformity  is 
hideous,  and  necessitates  a  mode  of  dress  to  conceal  it. 
The  patient  has  not  as  yet  been  operated  on  for  the  extir- 
pation of  the  growth,  owing  to  her  present  physical  con- 
dition, the  result  of  melancholia. 

Scanes-Spicer  injected  some  vaselin  to  correct  a  sad- 
dle nose  with  satisfactory  immediate  result,  but  after 
several  days  the  upper  lids  became  slightly  edematous, 
and  soon  after  a  small  hard  lump,  the  size  of  a  grain  of 
shot,  was  felt  in  the  left  upper  lid. 

Harmon  Smith  observed  a  secondary  diffusion  in  two 
cases  in  which  the  abnormality  in  one  occurred  on  the 
side  of  the  nose  and  in  the  other  at  the  inner  canthus  fol- 
lowing the  course  of  the  angular  vein. 


HYDROCARBON  PROTHESES      255 

While  in  the  foregoing  cases  the  difficulty  may  have 
been  overcome  by  using  the  cold,  semisolid  paraffin  mix- 
ture and  reducing  the  amount  injected,  it  is  questionable 
if  the  diffusion  could  thus  have  been  entirely  overcome. 

The  author  points  to  the  fact  that  undoubtedly  this 
fault  is  observed  more  when  the  tissues  at  the  side  of  the 
nose,  or  about  the  alae,  are  injected,  and  that  the  cause 
here  is  one  of  an  unequal  pressure  of  the  parts — the  skin 
more  or  less  bound  down  above  and  the  ungiving  carti- 
lage below. 

In  such  cases  great  care  should  be  exercised  in  the 
amount  injected,  and  if,  after  introducing  the  needle, 
the  tissue  be  found  to  be  unduly  adherent  and  inelastic, 
to  withdraw  the  needle  and  with  a  fine  tenotome  divide 
or  dissect  up  the  skin  before  the  mass  is  injected.  At  no 
time  would  an  operator  be  justified  to  inject  more  than 
ten  drops  of  the  mass,  at  a  single  operation,  into  the  parts 
referred  to. 

As  already  mentioned,  there  is  not  only  danger  of 
diffusion  of  the  mass  in  such  region  of  the  nose,  including 
the  lobule  and  the  subseptum,  but  there  is  a  special  dan- 
gere  of  gangrene  from  pressure  where  the  tissues  are  less 
supportative  than  where  muscular  tissue  or  greater  mo- 
bility of  the  skin  is  found. 

After  the  immediate  attempts  to  reduce  a  reactive  in- 
flammation, nothing  can  be  done  to  overcome  secondary 
diffusion  except  excision  of  the  amount  not  wanted.  This 
should  not  be  undertaken  until  at  least  three  months  after 
the  time  of  injection. 

The  mass  of  connective  tissue  must  be  entirely  excised 
as  thoroughly  as  possible,  and  slightly  beyond  the  border 
of  the  abnormal  elevation.  A  sharp  curette  is  practically 
of  no  use  for  this  purpose,  and  only  wounds  the  skin,  and 
by  reason  of  retentive  shreds  of  tissue  may  cause  infect- 
ive inflammation. 

The  opening  into  the  skin  should  be  made  with  a  fine 
bistoury,  the  skin  be  dissected  off  from  the  elevated  con- 


256      PLASTIC    AND    COSMETIC    SURGERY 

nective  tissue,  and  the  latter  extirpated  by  dipping  cuts 
of  a  fine  small,  sharp-pointed,  half-rounded  scissors.  The 
operation  can  be  done  neatly  and  painlessly  under  eu- 
cain  anesthesia. 

The  wound  may  be  sutured  with  fine  silk  or  be  al- 
lowed to  unite  of  its  own  accord. 

It  is  advisable  to  supply  a  small  pressure  dressing, 
made  of  a  circular  gauze  pad,  over  the  site  to  assure  of 
the  best  union  between  the  dissected  or  undersurface  of 
the  skin  and  the  floor  of  the  wound. 

Dry  dressings  are  to  be  preferred,  since  moisture 
would  tend  to  soften  the  skin  and  permit  it  to  crawl, 
which  would  not  improve  the  ultimate  result. 

20.  Hyperplasia  of  the  Connective  Tissue  following  the  Organ- 
ization of  the  Injected  Matter. — The  overproduction  of  con- 
nective tissue  replacing  the  injected  mass  is  rarely  ob- 
served, yet  a  few  cases  have  been  noted. 

Sebileau  has  reported  a  true  case  of  diffuse  fibroma- 
tosis  following  an  injection  of  paraffin.  This  not  only 
included  the  site  of  the  injection,  but  extended  to  the 
surrounding  or  adjacent  tissue,  making  the  secondary 
defect  much  more  disfiguring  than  the  first. 

The  author  has  observed  in  one  case  of  hyperplasia 
following  the  correction  of  a  saddle  nose,  that  the  area 
injected  presented  no  unusual  appearance  for  six  months, 
when  the  nose  at  its  middle  third  began  to  enlarge  slowly 
until  it  resembled  a  marked  Roman  shape,  the  enlarge- 
ment extending  laterally  and  as  far  down  as  the  naso- 
genian  furrows  at  the  end  of  nine  months. 

The  injection  used  was  a  cold,  semisolid  paraffin  mix- 
ture, and  only  sufficient  to  barely  correct  the  defect  was 
injected,  the  skin  being  thoroughly  flexible  at  the  time 
of  operation. 

No  reason  can,  therefore,  be  given  for  this  unusual 
result,  except,  perhaps,  a  peculiar  idiosyncrasy  of  the 
tissues,  that  may  be  compared,  somewhat,  with  the  exter- 
nal tissue  changes  in  hypertrophic  or  keloidal  scars,  espe- 


HYDROCARBON  PROTHESES      257 

cially  noted  in  the  wounds  of  negroes — a  condition  for 
which  we  have,  as  yet,  found  no  attributable  cause. 

While  we  cann'ot  definitely  prevent  such  a  result,  fol- 
lowing an  injection  of  a  hydrocarbon,  we  may  at  least 
be  sure  that  hyperinjection  is  not  the  cause. 

The  hyperplasia  as  exhibited  in  these  cases  is  one 
of  true  fibromatosis.  The  microscopical  examination 
may  show  the  retention  of  paraffin  in  small,  round,  pearl  - 
like  masses  lying  in  cells  of  varying  size,  but  with  speci- 
mens of  such  tissue  removed  after  a  number  of  years' 
standing  does  not  show  the  paraffin  in  situ. 

In  a  specimen  taken  from  a  chin  five  years  after  the 
injection  of  paraffin  the  Lederle  Laboratory  makes  the 
following  report  accompanied  by  microphotographs  of 
sections  taken  from  the  fibromatous  area  as  shown  in 
Figs.  2S8a  and  288fc : 

"  ANATOMIC  DIAGNOSIS. — The  specimen  consists  of 
several  pale,  tough  masses  of  tissue  removed  from  the 
chin  covered  on  the  outside  by  normal  skin. 

"  HISTOLOGIC  DIAGNOSIS. — The  various  layers  of  the 
epidermis — i.  e.,  the  strata  corneum,  lucidum,  and  granu- 
losum — are  unthickened  and  practically  normal.  In  the 
corium  the  papillary  and  reticular  layers  are  apparently 
normal,  showing  no  thickening  nor  round-cell  infiltration. 

"  The  glandular  elements  in  this  area  and  the  hair  fol- 
licles appear  normal. 

"  Toward  the  deeper  layers  and  the  subcutaneous  con- 
nective tissues  appear  isolated  areas  of  round-cell  in- 
filtration separated  by  masses  of  fibrous  connective  tis- 
sue, much  of  which  is  of  new  formation,  as  indicated  by 
the  nucleated  character  of  the  elongated  cells.  There 
are  areas  of  diffuse  round-cell  infiltration. 

"  In  this  portion  of  the  corium  there  is  also  to  be  found 
a  large  number  of  vacuolated  areas  varying  very  greatly 
in  size,  and  which  are  surrounded  by  membranous  fibrous- 
tissue  elements,  much  of  which  is  likewise  of  new  forma- 
tion, as  indicated  by  the  character  of  its  cells. 

18 


258     PLASTIC   AND    COSMETIC    SURGERY 

"  These  vacuoles  doubtless  represent  the  areas  con- 
taining the  masses  of  paraffin  which  have  been  split  up  by 
the  new  formation  of  fibrous  tissue.  Between  the  vacuo- 
lated  areas  can  be  seen  actual  infiltration  by  true  fat 
cells. 

"  In  many  spots  the  fibrous-tissue  formation  has  pro- 
ceeded to  the  point  of  thick  bands  containing  but  few 
nucleated  cells.  Fig.  288«,  which  is  a  photomicrograph 
of  this  portion  of  the  section,  shows  these  changes. 

"  In  one  of  the  foci  of  round-cell  infiltration  which 
have  been  surrounded  and  invaded  by  bands  of  new 
fibrous  tissue  there  are  numerous  giant  cells  of  the  so- 
called  '  foreign-body '  type.  This  is  shown  in  Fig.  288fc. 

"  SUMMARY. — Histological  Diagnosis. — Diffuse  fibro- 
matories  with  fatty  infiltration  and  giant-cell  formation 
in  a  vacuolated  area  produced  by  paraffin  injection." 

Once  the  hyperplasia  is  established  the  surgeon  must 
simply  wait  until  he  believes  the  activity  of  the  abnormal 
growth  has  subsided  and  then  remove  the  superabundant 
tissue  with  the  knife. 

With  another  case,  in  which  the  patient  was  operated 
on  by  another  surgeon,  the  author  was  called  upon  to 
remove  the  growth.  A  part  of  the  coarse,  yellowish  pale 
and  cartilagelike  tissue  was  excised,  sufficient  to  restore 
the  parts  to  a  normal  contour.  After  an  uneventful  re- 
covery the  patient  went  away,  greatly  pleased,  only  to 
return  in  six  months,  presenting  a  similar  condition  as 
before  the  extirpation. 

A  second  operation  was  done,  this  time  more  exten- 
sively, the  entire  yellowish  connective  tissue  being  re- 
moved by  the  aid  of  a  long  median  incision  on  the  ante- 
rior aspect  of  the  nose. 

The  wound  healed  readily  and  showed  very  little  scar, 
and  the  patient  was  discharged.  One  year  after  the  last 
operation  the  nose  was  still  normal  in  appearance  and 
the  growth  had  not  reappeared. 

From  this  it  is  deemed  absolutely  necessary  to  re- 


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HYDROCARBON  PROTHESES      259 

move  practically  all  of  the  newly  formed  tissue  to  war- 
rant a  nonrecurrence  of  the  fibromatosis. 

21.  A  Yellow  Appearance  and  Thickening  of  the  Skin  after  Or- 
ganization of  the  Injected  Mass  Has  Taken  Place. — This  condi- 
tion of  the  skin  is  evidenced  some  time  after  the  injected 
mass  has  become  organized,  beginning  about  the  sixth 
month  after  the  time  of  injection.  It  has  been  especially 
noticed  with  the  hard  paraffin  fillings  of  the  nose,  but 
also  with  other  injections,  even  of  the  lowest  melting 
points,  about  the  sternoclavicular  regions  of  the  neck. 

The  skin  becomes  at  first  streaked  with  a  superficial 
and  irregularly  defined  patch  of  red,  the  forerunning  in- 
dication of  the  size  of  the  ultimate  pathological  change. 
The  red  color  subsides  slowly,  leaving  the  area  pale, 
which  thereafter  gradually  thickens,  taking  on  the  ap- 
pearance of  a  light  yellow  stain  in  the  skin. 

Practically  opposite  to  the  condition  in  xanthalasma, 
where  the  yellow  area  is  slightly  elevated  and  occurs  in 
the  loose  tissue  of  the  eyelids. 

The  cause  seems  to  be  a  degenerative  change  in  the 
skin  dependent  on  pressure  upon  its  underlying  tissues. 
Evidently  the  pressure  of  an  overproduction  of  the  con- 
nective tissue  which  has  sprung  up  to  replace  the  in- 
jected mass. 

Seemingly  the  cause  is  due  to  an  injection  being 
made  too  close  to  the  derma  where  the  latter  is  bound 
down  to  the  subcutaneous  tissue,  or  a  desire  on  the  part 
of  the  surgeon  to  prevent  an  injection  into  the  deeper 
areolar  tissue,  especially  when  the  injection  is  made  in 
the  vicinity  of  the  larger  blood  vessels,  for  fear  of  caus- 
ing embolisms  or  phlebitis. 

Excluding  the  use  of  hard  paraffin  for  such  injection, 
the  operator  should  be  sufficiently  experienced  to  use 
these  injections  properly  and  without  fear,  and  at  all 
times  avoid  injecting  into  the  skin  instead  of  subcuta- 
neously. 

Making  the  puncture   first   and  observing   if  blood 


260      PLASTIC   AND    COSMETIC    SURGERY 

flows  freely  or  trickles  from  the  detached  needle  will 
assure  the  operator  into  what  tissues  he  has  thrust  his 
needle. 

Should  active  bleeding  follow  the  puncture,  he  should 
withdraw  the  needle  and  wait  to  inject  the  site  at  a  later 
sitting,  using  the  same  precaution ;  at  no  time  should  he 
be  in  doubt  as  to  the  absolute  placing  of  the  injected 
mass. 

When  the  injections  are  done  about  the  lower  neck 
or  shoulders  great  care  must  be  exercised  to  avoid  the 
blood  vessels,  and  small  quantities  be  only  injected  to 
prevent  reactions  that  may  cause  phlebitis  of  these  ves- 
sels; furthermore,  the  injected  mass  must  be  carefully 
molded  to  prevent  the  formation  of  uneven  elevations  or 
lumps.  Without  doubt  an  injection  into  one  of  the  blood 
vessels  of  the  neck  would  mean  certain  death. 

Kofman  lost  a  patient  by  pulmonary  embolism 
twenty-four  hours  after  an  injection  of  10  c.c.  of  paraf- 
fin. How  many  punctures  he  made  to  inject  this  amount 
is  not  stated,  but  certain  it  must  be  that  he  introduced 
part  of  the  mass  directly  into  some  blood  vessel. 

The  author  advises,  when  injecting  about  the  neck, 
to  use  a  stout,  dull-pointed  needle  introduced  under  local 
ethyl  chloride  anesthesia  and  to  elevate  the  tissue  with 
the  needle  as  the  injection  is  made.  In  this  way  the 
operator  can  observe  the  behavior  or  placing  of  the  in- 
jected mass,  at  the  same  time  stretching  the  skin  to  per- 
mit of  the  injection  without  encroaching  upon  the  blood 
vessels.  The  mass  is  immediately  molded  after  each  in- 
jection. The  further  question  of  the  practical  method 
of  making  these  injections  will  be  fully  considered 
later. 

If,  however,  the  pigmentation  under  consideration  has 
taken  place,  electrolysis  with  a  fine  needle  may  be  re- 
sorted to,  with  the  object  of  whitening  the  discoloration 
by  producing  scar  tissue,  in  the  form  of  punctations,  in 
the  discolored  area. 


HYDROCARBON  PBOTHESES      261 

While  the  numerous  white  spots  so  caused  are  objee- 
tionable,  they  are  better  borne  by  patients  than  the  pig- 
mented  appearance.  A  thorough  needling  of  the  spot 
in  this  way  eventually  brings  about  an  improvement,  and 
if,  for  aesthetic  reasons,  the  patient  objects  to  the  un- 
sightliness  of  the  result  thus  obtained,  the  white  area  may 
be  carefully  tattooed  with  an  appropriate  color  to  match 
the  rest  of  the  skin  of  the  face  or  neck. 

If  the  pigmented  area  is  not  too  large,  it  can  be  ex- 
cised with  the  knife  and  the  healthy  skin  be  brought 
together  with  a  fine  silk  suture,  thus  leaving  a  thin  linear 
scar  which  can  be  dealt  with  as  the  punctate  scar  area, 
if  desired;  the  electrolysis  being  a  painful  procedure  at 
all  times,  since  sufficient  milliamperes  must  be  used  to 
cause  scar-tissue  formation,  which  is  between  20  to  30 
milliamperes  in  such  cases. 

22.  The  Breaking  Down  of  Tissue  and  Resultant  Abscess  Due 
to  the  Pressure  of  the  Injected  Mass  upon  the  Adjacent  Tissue  after 
the  Injection  Has  Become  Organized. — The  above  result  is  par- 
ticularly noticeable  when  the  injections  have  been  made 
into  the  cheek  or  the  breast.  It  is  understood  that  the 
suppurative  changes  under  consideration  herein  are  not 
attributable  to  imperfect  sterilization  of  the  injected  mat- 
ter, although  it  is  possible,  and  perhaps  is  the  cause  in 
fifty  per  cent  of  the  suppurative  elimination  of  the  in- 
fected mass  from  the  cheek,  that  a  nucleus  of  infection 
is  carried  into  the  tissues  and  is  held  in  suspense  for  a 
time,  because  of  its  imbedment  in  a  neutral  media  that 
does  not  readily  permit  of  bacteriological  propagation, 
but  eventually  this  nucleus  must  come  in  contact  with 
tissue  which  it  can  affect,  and  only  then  may  its  infection 
be  taken  up. 

The  author  believes  that  such  secondary  affections 
are  accountable  to  pressure  effects  upon  the  blood  vessels 
or  glandular  structure,  as  in  the  case  of  breast  injections, 
the  new  connective  tissue  causing  a  lack  of  nourishment 
in  the  part  or  gland,  and  a  resultant  breaking  down  of  the 


262      PLASTIC    AND    COSMETIC    SURGERY 

tissue,  directly  influenced  in  some  instances  by  external 
violence. 

Tuffier  reports  the  elimination  of  paraffin  injected 
into  the  breast  several  weeks  after  the  injection.  If  this 
elimination  had  been  caused  by  primary  infection  an 
acute  reaction  would  have  taken  place  at  least  within 
forty-eight  hours,  ending  in  abscess  shortly  after. 

A  case  which  came  to  the  author's  attention  was  that 
of  a  lady  who  had  been  operated  upon  for  the  correction 
of  a  saddle  nose  three  months  before.  The  result  had 
been  satisfactory.  The  day  previous  to  consulting  the 
author  she  had  injured  her  nose  in  an  automobile  acci- 
dent. The  nose  was  much  swollen,  very  painful,  and  red 
over  the  entire  upper  and  middle  third.  The  use  of  exter- 
nal cold  did  not  relieve  the  condition  much,  and  on  the 
fourth  day  the  skin  broke  open  at  one  point,  allowing 
pieces  of  the  paraffin  to  escape.  Immediate  relief  fol- 
lowed, the  wound  healed  with  a  marked  sinking  of  the 
middle  third  of  the  nose.  After  three  weeks  the  nose  was 
again  injected  with  no  further  untoward  symptoms,  the 
result  being  satisfactory  for  two  years  past. 

In  this  case  undoubtedly  the  exciting  cause  was  di- 
rectly due  to  violence,  which  may  be  the  forerunner  in 
many  of  such  cases,  but  there  is  a  number  of  such  elimi- 
nations directly  due  to  a  breaking  down  of  the  tissue 
from  internal  pressure  alone. 

There  is  no  way  to  overcome  this  difficulty,  except  to 
await  the  definite  formation  of  the  abscess  and  then  to 
puncture  the  skin  directly  over  the  soft  fluctuating  area 
and  to  drain  the  cavity. 

Once  relieved,  the  condition  quickly  subsides,  leaving 
a  certain  amount  of  loss  of  contour,  which  can,  however, 
be  corrected  several  weeks  after  by  a  secondary  in- 
jection. 

When  the  abscess  occurs  in  the  cheek  it  is  not  advis- 
able to  open  interiorly,  but  to  make  the  puncture  through 
the  skin,  on  account  of  the  danger  of  infection  from  the 


HYDROCARBON  PROTHESES      263 

buccal  cavity  and  of  the  imperfect  evacuation  thus  at- 
tained. 

A  trocar  and  cannula  of  proper  size  will  be  found  to 
be  the  most  suitable,  the  parts  being  gently  manipu- 
lated to  evacuate  the  contents  of  the  abscess. 

Aspiration  can  also  be  resorted  to,  but  for  the  breast  a 
small  linear  incision,  made  under  local  anesthesia  at  the 
most  dependent  point,  best  answers  the  purpose. 

A  small  gauze  strip  drain  may  be  employed  for  a  few 
days  to  insure  of  perfect  drainage  in  the  latter  case,  the 
wound  being  brought  together  eventually  by  a  delicate 
cosmetic  operation  if  desirable. 

THE   PROPER  INSTRUMENTS  FOR  THE  SUBCUTANE- 
OUS  INJECTION    OF   HYDROCARBON   PROTHESES 

Although  Gersuny  advocated  the  use  of  a  Pravaz  syr- 
inge for  injecting  the  liquefied  vaselin  mixture  for  pro- 
thetic  purposes,  it  was  soon  found  that  such  an  instru- 
ment was  practically  useless,  especially  when  the  parts  to 
be  injected  offered  more  or  less  resistance  to  the  intro- 
duction of  the  foreign  matter. 

Other  operators,  following  the  advice  of  Eckstein, 
who  advised  the  employment  of  "  Hart  paraffin  "  of  high 
melting  point  liquefied  by  heat,  raised  the  objection  that 
the  metal  needle  became  so  easily  obstructed  by  the  rapid 
setting  of  the  paraffin  in  its  distal  end  that  the  great 
force  necessary  to  eject  the  contents  of  the  syringe  usu- 
ally resulted  in  a  breakage  of  the  glass  barrel  in  the 
hands  of  the  operator,  or,  as  in  some  types  of  the  syringe, 
a  separation  of  needle  and  syringe  at  the  point  where  the 
former  was  slipped  upon  the  ground  point  of  the  latter, 
with  the  annoyance  of  the  paraffin  squirting  over  the 
faces  of  both  patient  and  operator. 

Eckstein  tells  us  how  to  overcome  the  first  difficulty 
with  this  same  style  of  syringe  as  used  by  him.  He  cov- 
ers the  syringe  with  a  rubber  insulating  sleeve  and  draws 


264      PLASTIC    AND    COSMETIC    SURGERY 

several  drops  of  hot,  sterilized  water  into  the  needle  to 
overcome  the  plugging  up  of  the  latter;  an  illustration 
of  his  syringe  has  been  shown  on  page  232.  Mention 
has  also  been  made  of  the  various  methods  used  to  over- 
come this  difficulty  by  other  operators. 

It  was  presently  found  that  such  an  instrument  was 
not  only  impractical,  but  also  a  detriment  to  procuring 
desirable  results,  the  paraffin  solution  shooting  out  sud- 
denly, in  some  instances  causing  hyperinjection,  and  at 
other  times  emerging  so  slowly  that  it  required  unusual 
force  on  the  part  of  the  operator — a  painful  procedure 
for  delicate  hands,  inasmuch  as  the  fingers  only  can  be 
applied  to  operate  the  instrument. 

With  the  object  of  overcoming  this  uncertainty  of  the 
amount  of  the  injection  and  the  unnecessary  exertion  to 
inject  any  given  quantity,  as  well  as  to  establish  enough 
vice  a  tergo  to  keep  the  needle  free  from  plugging  up 
with  cooling  paraffin,  various  operators  devised  instru- 
ments, all  having  practically  similar  points  of  mechan- 
ical merit  and  usefulness.  The  required  necessities  being 
to  invent  a  syringe  which  would  have  a  known  capacity, 
a  piston  under  control  of  the  operator  at  all  times,  and 
metallic  needles  of  proper  lumen,  to  prevent  the  solidifi- 
cation of  the  liquid  paraffin,  screwed  to  the  syringe  to 
prevent  loosening. 

With  the  object  of  overcoming  these  difficulties  the 
author  devised  a  syringe  which  was  made  for  him  by 
Tiemann  &  Co.,  early  in  1902.  He  begs  to  introduce  the 
same  here,  as  a  type  similar  to  which  most  operators 
have  built  their  special  instrument. 

The  syringe  at  that  time  consisted  of  a  glass  barrel, 
of  a  size  to  hold  6  c.c.  of  liquefied  paraffin.  At  either 
end  of  the  barrel  tube  were  placed  metal  ends,  the  distal 
one  containing  a  cap  with  a  screw  thread  to  receive  the 
needle,  the  upper  cap  being  threaded  to  receive  a  check 
nut  through  its  center  and  on  its  outer  surface,  on  oppo- 
site sides  to  each  other,  two  metallic  rings  to  accommo- 


HYDROCARBON    PROTHESES 


265 


date  the  thumb  and  forefinger.  The  center  of  the  check 
nut  was  double  threaded  to  receive  the  piston  rod,  the 
piston  or  plunger  being  held  in  place  by  two,  upper  and 
lower,  washer  nuts,  the  lower  being  threaded  to  receive 
a  small  rod  passing  through  the  bored-out  center  of  the 
piston  rod,  and  which  ended  in  a  check  nut,  in  the  handle, 
threaded  upon  the  outer  or  manual  end  of  the  piston  rod, 
in  such  a  way  that  the  fiber  or  asbestos  piston  washer 
could  be  tightened  and  loosened  at  will. 

The  syringe  permitted  of  being  used  as  an  ordinary 
syringe  by  unscrewing  the  cap  check  nut  or  be  made  into 


FIG.  289. — AUTHOR'S  DROP  SYRINGE. 

a  screw  drop  syringe  by  screwing  the  same  nut  into  place. 
By  turning  the  handle  end  of  the  piston  rod  the  contents 
of  the  syringe  were  forced  out  smoothly  and  evenly  in 
any  quantity  desired. 

With  the  later  employment  of  the  cold,  semisolid 
preparation  of  vaselin  and  paraffin,  as  heretofore  con- 
sidered, it  was  found  necessary  to  reenforce  this  syringe, 
so  that  the  greater  pressure  necessary  to  eliminate  the 
wormlike  thread  of  hydrocarbon  would  not  force  off  the 
lower  cap  or  break  the  barrel  of  the  syringe  at  its  needle 
end. 

This  was  done  for  the  author  by  the  Kny-Scheerer 
Company,  December  6,  1902,  when  metallic  strips  were 
added  to  opposite  sides  of  the  glass  barrel  connecting 
the  lower  with  the  upper  cap. 


266      PLASTIC   AND    COSMETIC    SURGERY 

The  instrument  as  then  made  is  shown  in  Fig.  289. 

At  the  same  time  the  same  firm  made  the  author  a 
syringe  entirely  of  metal,  similar  in  construction,  except 
that  the  barrel  was  made  larger  in  diameter  and  shorter 
in  proportion  to  bring  the  instrument  near  to  the  seat  of 
operation.  The  regulating  washer  rod  was  not  needed, 
since  in  this  instrument  no  washers  were  required,  the 
piston  head  being  made  of  solid  metal  throughout  and 
the  rod  being  soldered  to  the  plunger,  thus  overcoming 
any  objectionable  fault  in  sterilization. 

This  type  of  syringe  was  found  to  be  most  suitable 
for  the  cold,  semisolid  injections,  and  is  of  the  type  now 


FIG.  290. — AUTHOR'S  ALL-METAL  DROP  SYRINGE. 

universally  used  except  for  the  slight  modifications  of 
the  various  operators.    It  is  illustrated  in  Fig.  290. 

Since  there  were  no  objections  to  making  the  barrel 
large  enough  to  permit  of  injections,  such  as  are  required 
for  restoring  the  contour  of  the  cheek  and  the  neck  and 
shoulder,  it  was  made  to  contain  10  c.c.  working  capacity, 
overcoming  the  necessity  of  constant  refilling,  when  com- 
paratively large  injections  had  to  be  made — a  fact  worth 
remembering  from  a  practical  standpoint,  although  two 
or  three  of  these  syringes,  specially  prepared  for  each 
patient,  might  be  found  desirable  by  some  operators. 
Yet  the  simplicity  and  ready  facility  with  which  this 
instrument  can  be  used  and  refilled  renders  it  useful  and 
sufficient  for  performing  operations  of  this  nature  to 
any  judicious  extent. 


HYDKOOABBON  PEOTHESES 


267 


Syringes  holding  small  quantities  of  the  paraffin  mix- 
ture are  found  to  be  a  nuisance. 

The  following  operators  employ  syringes  of  the  ca- 
pacity given : 

Broecksert .    . . .  3      c.c.    50  mm. 

Eckstein  .    ... 5     c.c.    80  mm. 

Freeman 5.6  c/c.     90  mm. 

Downie 10     c.c.  150  mm. 

The  instrument  employed  by  Broeckaert,  holding  less 
than  one  dram,  would  be  of  little  use  except  to  correct 
very  slight  deformities  about  the  brow  or  nose,  or  dress- 
ing up  or  completing  the  contour  of  parts  previously 
filled  by  larger  injections. 

Another  syringe  similar  in  type  to  the  author's,  but 
of  a  capacity  of  5.6  c.c.,  was  introduced  by  Harmon 
Smith. 

The  principles  of  the  syringe  are  alike,  but  the  style 
of  handles,  two  flat  metal  bars  at  opposite  sides,  offers 
no  objection  when  comparatively  hard  mixtures  of  par- 
affin and  vaselin  are  used. 

While  operating  the  syringe  the  narrow  blades  are 
brought  in  contact  with  the  soft  flexor  sides  of  the  thumb 


FIG.  291. — SMITH  ALL-METAL  DROP  SYRINGE. 

and  forefinger,  indenting  the  flesh  deeply,  and  with  the 
least  unexpected  move  on  the  part  of  the  patient  per- 
mitting it  to  slip  out  of  the  grasp  of  the  surgeon.  Its 
incapacity  for  large  injections  also  offers  some  objection, 


268      PLASTIC    AND    COSMETIC    SURGERY 

but  for  correcting  smaller  defects  it  is  both  practical  and 
compact.  It  is  illustrated  in  Fig.  291. 

It  is  obvious  that  with  the  screw  drop  type  of  syringe 
the  cold  semisolid  paraffin  mixture  contained  in  its  bar- 
rel is  always  under  the  full  command  of  the  operator, 
nor  can  there  be  a  plugging  of  the  needle,  since  the  great 
force  that  can  be  exerted  with  a  turn  of  the  piston  han- 
dle would  free  it,  even  if  the  mixture  were  of  a  compara- 
tively high  melting  point,  although  the  force  to  be  ap- 
plied would  naturally  increase  in  proportion  to  the  hard- 
ness of  the  mass  within  the  syringe. 

The  turning  of  the  screw  piston  forces  out  the  contents 
of  the  syringe  in  the  form  of  a  white  thread  of  a  diam- 
eter equal  to  the  diameter  of  the  lumen  of  the  needle. 

To  facilitate  this  ejection,  the  needles  should  be  of 
ample  diameter,  not  over  one  inch  long  and  having  knife- 
edged  points.  Longer  needles  are  not  necessary,  and 
only  add  to  the  force  required  to  turn  the  screw  handle. 

Curved  needles,  used  by  some  operators,  are  never 
needed,  and  the  author  does  not  see  how  they  could  be 
applied  at  any  time  in  preference  to  the  straight. 

As  much  of  the  paraffin  mixture  can  be  forced  out  of 
the  syringe  as  may  be  desired  by  screwing  the  piston 
down  into  the  barrel. 

The  piston  rod  may  be  graduated  in  five-  or  ten-drop 
divisions,  but  the  operator  rarely  ever  refers  to  the  scale. 
He  judges  the  amount  required  by  the  elevation  of  the 
tissues  brought  about  by  the  presence  of  the  paraffin  thus 
forced  under  the  tissue.  Experience  soon  teaches  him 
the  amounts  necessary  or  judicious  in  each  case,  always 
remembering  that  it  is  better  to  do  a  second  and  later 
injection  than  to  hyperinject. 

The  entire  instrument  being  of  metal  permits  it  to 
be  sterilized  as  readily  and  in  the  same  manner  as  any 
other  metallic  instrument. 

It  is  understood  that  the  syringe  must  be  taken  apart 
for  sterilization  at  all  times. 


HYDROCARBON  PROTHESES      269 

Lubrication,  to  facilitate  operation,  is  never  required, 
since  the  nature  of  the  mixture  used  in  the  syringe  an- 
swers this  purpose  in  every  way. 

Owing  to  the  greater  amount  of  metal  in  the  solid 
piston  itself,  the  latter  is  very  likely  to  expand  under 
dry  heat  sterilization  or  boiling,  so  much  so  that  for  a 
moment  it  cannot  be  introduced  within  the  barrel.  This 
can  be  quickly  overcome  by  dipping  it  into  cold  sterile 
water  or  absolute  alcohol,  which  brings  about  its  con- 
traction. 

After  using,  the  syringe  should  be  emptied  entirely, 
unscrewed  and  sterilized,  and  placed  in  the  metal  case 
furnished  for  it.  A  screw  cap  is  furnished  to  take  the 
place  of  the  needle  when  not  in  use. 

The  method  of  filling  and  using  the  syringe  will  be 
considered  later. 

PREPARATION   OF  THE  SITE   OF   OPERATION 

The  same  surgical  precautions  should  be  observed 
when  a  paraffin  injection  is  to  be  undertaken,  as  with  a 
minor  surgical  operation. 

It  is  hardly  found  necessary  to  prepare  the  site  of 
operation  the  day  before,  nor  need  the  patient  be  detained 
for  such  time  for  the  purpose  of  making  him  ready. 

With  careful  observance  of  ordinary  surgical  tech- 
nique, both  as  to  surgeon  and  patient,  all  of  this  class  of 
operations  can  be  performed  in  any  physician's  office, 
providing  that  both  instruments  and  the  mass  to  be  in- 
jected have  been  rendered  sterile. 

Especial  care  should  be  given  to  the  operator's  hands, 
for  with  these  he  not  only  handles  the  instruments,  but 
must  also  mold  the  mass  injected,  thus  frequently  com- 
ing in  contact  with  the  needle  opening  or  openings  made 
in  the  skin. 

When  injections  are  to  be  made  in  the  cheeks  of  the 
patient,  the  mouth  should  be  prepared  by  cleansing  the 


270     PLASTIC   AND    COSMETIC    SURGERY 

teeth  thoroughly  and  washing  out  the  buccal  cavity  with 
warm  boric  acid  or  hydrogen  peroxid  solution,  or  any  of 
the  preparations  of  the  Listerine  composition. 

This  rinsing  should  be  continued  every  few  minutes 
for  at  least  ten  minutes  before  the  operation  is  under- 
taken. 

This  is  necessary,  as  the  surgeon  must  introduce  his 
finger  into  the  mouth  and  behind  the  cheek  to  mold  out 
the  mass  injected  subcutaneously,  and  infection  could 
easily  be  introduced  by  his  fingers  during  this  procedure. 

Externally  a  generous  field  of  the  operation  is 
scrubbed  with  a  brush  dipped  into  green  soap  and  water. 

The  skin  is  then  thoroughly  washed  with  gauze 
sponges  steeped  in  absolute  alcohol,  followed  with  spong- 
ings  with  a  1-5,000  solution  of  bichlorid  of  mercury. 
The  whole  surface  is  then  wiped  off  with  a  sponge  dipped 
in  ether  and  covered  for  the  time  being  with  a  pad  of 
sterilized  gauze  until  the  operator  is  ready  to  proceed 
with  the  operation. 

PREPARATION   OF  THE  INSTRUMENTS  FOR 
OPERATION 

The  manner  of  preparing  the  necessary  mixture  of 
paraffin  has  been  described  on  page  244.  After  such 
preparation,  the  mixture,  still  hot,  may  be  poured  into 
test  tubes,  which  are  sealed  and  put  away  for  further 
use,  each  tube  holding  just  enough  to  fill  the  syringe  two 
thirds  full. 

When  a  syringe  is  to  be  filled,  one  of  the  tubes  is 
opened  and  the  contents  are  again  boiled  over  a  spirit 
flame,  or  simply  liquefied  and  poured  into  one  of  the 
types  of  heaters  already  described  for  the  same  purpose 
of  resterilization. 

From  the  test  tubes  or  the  heater,  the  boiling  mixture 
may  be  drawn  up  into  the  sterilized  syringe  to  the  re- 
quired amount  or  it  may  be  poured  into  the  opened  piston 
screw  cap  end. 


HYDROCARBON  PROTHESES      271 

In  the  latter  event  the  ready  cooling  of  the  mixture 
as  it  enters  the  needle  will  permit  it  to  be  retained  in  the 
barrel,  or  the  needle  may  be  immersed  in  sterile  water  as 
the  paraffin  is  poured  into  the  syringe,  yet  even  if  a  few 
drops  escape  from  the  needle  in  the  former  method,  no 
harm  is  done,  as  such  loss  amounts  to  nothing  and  helps 
to  eventually  fill  the  syringe  evenly  and  free  of  air. 

If  the  mixture  is  drawn  up  into  the  barrel  to  the  re- 
quired height,  more  or  less  air  enters,  which  must  be  re- 
moved by  turning  the  syringe,  needle  up,  and  screwing 
up  the  piston  rod  until  either  the  liquid  or  cylindrical 
thread  of  the  cooled  mixture  appears. 

If  the  mixture  is  poured  into  the  syringe  the  piston 
is  slowly  pressed  into  the  barrel,  thus  allowing  the  air  to 
escape  along  its  sides  if  the  mixture  is  set,  or  if  warm 
the  syringe  is  turned  up  and  the  piston  screwed  into 
place.  As  this  is  done  the  few  drops  of  cooled  paraffin 
will  be  forced  from  the  needle  before  the  air  is  exhausted. 
The  screw  is  turned  until  the  paraffin  emerges  evenly 
from  the  needle. 

The  syringe  must  now  be  laid  aside,  or  placed  in 
sterile  water  of  the  temperature  of  the  room,  to  allow 
the  liquid  within  to  set  evenly  and  become  uniform  in 
consistency. 

The  operator  will  follow  what  method  he  pleases  in 
filling  his  syringe,  but  at  no  time  should  he  fill  it  with  the 
cooled  product  with  a  spatula,  or  other  such  means,  as 
he  is  sure  to  fill  it  unevenly  in  this  way,  incorporating  a 
number  of  air  spaces.  The  air  issues  from  time  to  time 
during  an  operation  with  sudden  sputtering  outbursts, 
that  not  only  tend  to  annoy  the  patient,  but  also  to 
frighten  him — the  shock  being  unusual  and  unexpected, 
while  the  air  thus  forced  into  the  subcutaneous  tissues 
puffs  out  the  parts  and  interferes  with  a  perception  of 
the  proper  amount  to  be  injected  and  adds  to  the  danger 
of  air  embolisms. 

Slipshod  methods  are  inexcusable,  and  should  not  be 


272     PLASTIC   AND    COSMETIC    SURGERY 

tolerated.  The  best  results  possible  should  be  given  the 
patient,  and  only  from  the  best  results  obtained  with  the 
best  care  can  the  most  reliable  data  be  attained,  all  help- 
ing to  fix  the  reliability,  efficacy,  and  exactitude  of  this 
branch  of  cosmetic  surgery. 


THE  PRACTICAL  TECHNIQUE 

The  field  of  operation  and  the  instruments  having 
been  properly  prepared,  as  described,  the  modus  oper- 
andi  must  next  be  considered. 

Since  the  various  parts  of  the  face  to  be  injected  de- 
mand specific  procedure,  they  will  be  considered  some- 
what individually  hereafter,  whereas  the  general  tech- 
nique, applicable  in  as  far  as  the  method  of  injection  is 
concerned  and  applying  similarly  in  all  cases,  may  tersely 
be  first  taken  up. 

Various  and  noted  surgeons  point  out  that  these  sub- 
cutaneous injections  should  be  made  under  general  anes- 
thesia, i.  e.,  ether,  while  others  consider  the  hypodermic 
use  of  cocaine  or  Eucain  j8  solution  in  one  to  four  per 
cent  necessary  to  accomplish  good  results. 

The  author  considers  the  method  in  the  first  case  ob- 
jectionable both  as  to  patient  and  operator,  entailing 
much  discomfort  to  the  one  operated  on  and  demanding 
an  unnecessary  waste  of  time  for  the  etherizing  and  re- 
covery. -Likewise  is  the  employment  of  a  local  anesthetic 
not  indicated  or  demanded,  since  the  operation  to  be 
undertaken  necessitates  only  the  pain  associated  with  the 
prick  of  the  needle  through  the  skin. 

The  objection  to  etherization  is  obvious,  while  the 
hypodermic  employment  of  any  local  anesthetic,  by  the 
very  fact  of  its  presence  of  volume  and  its  physiological 
action  upon  the  tissue,  tends  to  interfere  with  the  proper 
injection  of  the  parts  by  reason  of  temporary  swelling 
of  the  parts,  not  caused  by  the  later  injections  of  the  pro- 
thetic  mass. 


HYDKOCAKBON  PEOTHESES      273 

If  in  nervous  irritable  patients  an  anesthetic  is  re- 
quired to  allay  fear  it  is  best  to  use  the  ethyl-chlorid 
spray  upon  the  skin  sufficiently  to  overcome  the  sharp 
sting  of  the  needle  insertion.  For  this  purpose  the  ether 
spray  is  used  only  to  the  point  of  blanching  the  skin,  and 
no  longer. 

This  mode  of  procedure  is  especially  useful  when  a 
number  of  injections  are  to  be  made,  as  in  the  rounding 
out  of  a  cheek  or  of  the  shoulders,  in  which  the  contour 
cannot  be  restored  from  one  point  of  injection,  as  will 
hereinafter  be  described. 

The  patient,  being  now  in  readiness,  the  skin  over  the 
area  is  lifted  or  pinched  up  with  the  fingers  of  the  left 
hand  of  the  operator  as  a  guide  to  its  mobility  and  to 
steady  the  part. 

The  point  of  the  needle  is  now  forced  through  the 
skin  and  into  the  subcutaneous  tissue  at  a  point  along 
the  periphery  of  the  deformity  and  pushed  a  little  be- 
yond the  center  of  the  cavity  to  be  filled. 

The  elevation  of  the  skin  is  in  the  meantime  partly 
kept  up  with  the  needle  itself,  while  the  syringe  is 
grasped  with  the  freed  hand,  the  thumb  and  forefinger 
of  the  right  hand  being  placed  upon  the  handle  of  the 
screw  or  piston  rod,  which  they  must  rotate  to  force  the 
semisolid  mass  from  the  instrument. 

Before  beginning  the  injection  an  assistant  is  in- 
structed to  press  with  his  fingers  the  tissue  about  the 
margin  of  the  defect  to  prevent  the  filling  from  becoming 
misplaced  or  being  forced  into  undesirable  channels,  es- 
pecially if  the  skin  over  the  defect  is  found  to  be  thick 
and  inelastic. 

The  screw  handle  is  now  rotated  evenly  and  slowly, 
discharging  the  mass  to  be  injected,  which  will  soon  be 
evidenced  by  the  rise  of  the  skin  over  the  depression  to 
be  corrected. 

Only  sufficient  of  the  mass  must  be  injected  to  fairly 
correct,  never  to  overcorrect,  the  defect. 

19 


274      PLASTIC    AND    COSMETIC    SURGEKY 

Experience  alone  will  assure  the  surgeon  when  this 
point  has  been  attained,  since  he  cannot  immediately 
judge  the  necessary  amount  injected,  as  it  will  appear  as 
a  round  or  irregular  lump  under  the  skin,  until  it  has 
been  molded  or  worked  out  into  shape. 

Owing  to  the  pressure  exerted  upon  the  contents  of 
the  syringe,  which  will  continue  to  emerge  from  the 
needle  for  a  time,  the  needle  is  left  hi  place  for  a  few 
seconds  before  withdrawal,  so  that  the  needle  canal 
through  the  skin  will  not  become  filled  with  the  semisolid 
mixture. 

Such  blocking  up  of  the  opening  causes  a  cystic  de- 
velopment or  enlargement  about  the  opening  in  the  skin 
by  this  backing  up  or  exuding,  of  ttimes  crowding  itself  in 
between  the  layers  of  the  skin  and  necessitating  later  re- 
moval with  the  knife.  If  not  this  fault  it  tends  to  keep 
the  wound  open  unnecessarily  after  the  operation,  pre- 
venting healing  and  permitting  the  escape  of  a  certain 
amount  of  the  injected  mass,  if  a  mixture  of  low  melting 
point  has  been  utilized. 

The  needle,  having  been  allowed  to  remain  as  advised, 
is  now  withdrawn.  The  tip  of  one  finger  is  placed  over 
the  opening  in  the  skin  and  held  there  gently,  but  firmly, 
while  the  mass  is  molded  into  the  shape  required  or  de- 
sired with  the  fingers  of  the  right  hand. 

If  it  now  appears  that  the  injection  is  insufficient  the 
needle  may  again  be  introduced  through  the  same  open- 
ing and  more  is  injected,  remembering,  however,  that  if 
the  correction  is  quite  normal  no  more  should  be  added 
for  several  days,  or  until  the  injected  mass  has  be- 
come organized,  which  should  take  place  in  about  three 
weeks. 

If  it  is  found  that  the  skin  over  the  defect  is  inflexible 
and  bound  down,  it  will  be  found  advisable  to  sever  or 
dissect  subcutaneously  the  adhesions  that  bind  it  down 
with  the  use  of  a  fine  tenotome  or  a  spear-headed  para- 
centesis  knife. 


275 

This  may  be  done  two  or  three  days  before  the  parts 
are  injected  to  assure  the  surgeon  of  an  absolute  clean- 
liness of  the  wound. 

Mayo  advocates  the  injection  of  a  saline  solution  into 
subcutaneous  wounds  thus  made  as  a  guide  to  the  extent 
of  dissection  and  to  further  loosen  the  tissues. 

When  the  parts,  thus  loosened,  show  little  tendency 
to  bleed,  the  author  advocates  immediate  injection,  as  the 
waiting  for  several  days  permits  the  throwing  out  of  new 
connective-tissue  cells  that  interfere  to  a  certain  extent 
with  the  proper  injection  of  the  part. 

It  is  with  such  wounds  that  secondary  elimination  is 
most  likely  to  take  place,  especially  if  "  Hart  paraffin  "  or 
paraffin  of  a  high  melting  point  has  been  employed. 

This  is  undoubtedly  due  to  the  healing  down  and  con- 
traction of  the  margins  of  the  wound,  which  seems  to 
progress  more  and  more,  encroaching  eventually  upon 
the  hard  mass  and  ending  in  inflammation  of  the  over- 
lying skin  and  ultimate  elimination.  With  injections  of 
softer  consistency  this  is  less  frequent  and,  in  fact,  may 
be  entirely  overcome  by  limiting  the  amount  of  the  in- 
jection at  the  first  sitting,  relying  upon  a  full  correction 
for  later  operations,  when  the  periphery  of  the  wound 
has  become  more  or  less  influenced  by  the  presence  of  the 
neutral  mass  between  the  wounded  surfaces. 

The  subcutaneous  dissection  referred  to  must,  of 
course,  be  done  under  local  anesthesia,  preferably  the 
Schleich  mixture  or  a  one-per-cent  solution  of  Eucain  0. 

The  injection  of  the  paraffin,  or  hydrocarbon  mixture, 
in  semisolid  form,  having  been  made  and  properly 
molded  into  shape,  is  set  or  fixed  by  spraying  the  part 
with  ether  or  by  the  application  of  sterile  ice  cloths. 
When  liquid  paraffin  has  been  injected  it  will  be  noted 
that  the  paraffin  is  setting  contracts  upon  itself  con- 
siderably, leaving  less  of  a  correction  than  antici- 
pated. 

The  needle  opening  in  the  skin  is  next  washed  off 


276     PLASTIC    AND    COSMETIC    SURGERY 

with  a  twenty-five-per-cent  solution  of  hydrogen  peroxid 
and  closed  over  with  a  drop  of  collodion. 

The  patient  may  then  be  discharged  for  the  time 
being,  with  the  instruction  to  apply  ice  cloths  to  the  part 
for  at  least  twelve  hours  to  reduce,  as  far  as  possible, 
the  reactive  resultant  inflammation. 

On  the  third  day  the  collodion  patch  may  be  removed 
and  replaced  with  isinglass  adhesive  plaster  applied 
with  an  antiseptic  solution.  The  latter  is  allowed  to  re- 
main on  the  skin  until  it  falls  off. 


SPECIFIC    CLASSIFICATION    FOR    THE    EMPLOYMENT 

AND   INDICATION   OF  HYDROCARBON  PROTHESES 

ABOUT  THE  FACE 

Reference  has  been  made  heretofore  to  the  general 
indications  for  which  subcutaneous  injections  of  paraffin 
or  its  compounds  may  be  employed.  With  the  object  of 
systematizing  such  indications  and  to  further  bring  out 
the  practicability  and  judicious  use  of  the  method  under 
consideration  the  author  submits  the  following  tabulated 
arrangement,  with  the  hope  that  it  may  lead  to  a  more 
concise  and  better  knowledge  of  the  possibilities  within 
the  reach  of  the  plastic  or  cosmetic  surgeon. 

The  face  will  be  considered  in  such  grand  divisions 
as  are  easily  and  readily  understood,  the  defects  of  each 
part  being  shown  under  its  distinctive  regional  heading. 

DEFORMITIES  ABOUT  THE  FOREHEAD 

(  Punctate. 
Transverse  Depressions  -j  j  . 

Deficient  or  Receding  Forehead: 

(Exhibition  of  Undue  Superciliary  Ridges.) 

(  Surgical  (Frontal  Sinus). 
Unilateral  Deficiency  ^  m  A- 

I  Traumatic. 

(  Single. 

Intercihary  burrow  •{  ,  ,  ...  , 

I  Multiple. 

m  i  AT        i      T-V  c  •          i  Unilateral. 

Temporal  Muscular  Deficiency  •<  _,..  , 

J     Bilateral. 


HYDBOCABBON  PBOTHESES      277 

DEFORMITIES  OF  THE  NOSE 

Superior  Third. 
Middle        " 

Anterior  Nasal  Deficiency         -!  ,, 

Superior  Half. 

Inferior      " 
.  Total. 

Lateral  Insufficiency  \  Unilateral. 

I  Bilateral. 

Lobular  Insufficiency. 
Interlobular  Deficiency. 

Alar  Deficiency  \  Unilateral. 

1  Bilateral. 

Subseptal  Deficiency  \  Partial. 

(  Complete. 


DEFORMITIES  ABOUT  THE  MOUTH 

f  Unilateral. 
f  Upper  Lip  -I  Median. 

T   u-  i  T-V  c  •  [  Bilateral. 

Labial  Deficiency^  >TT 

f  Unilateral. 

L  Lower  Lip  <  Median, 
i.  Bilateral. 

Nasolabial  Furrow  -i  Unilateral. 

(  Bilateral. 

Oral  Angular  Furrow  -I  Unilateral. 

(  Bilateral. 


DEFORMITIES  ABOUT  THE  CHEEKS 

C  T  t  i  j  Unilateral. 

Deficiency  of  \  Bilateral. 

Cheek  1  (  Unilateral. 

L  Partial 

I  Bilateral. 


DEFORMITIES  ABOUT  THE  ORBIT 

(TT         T  -A  J  Unilateral. 
1  J  Bilateral. 
T  . ,  (  Unilateral. 
Lower  Lid  •(„.,.      , 
I  Bilateral, 


278     PLASTIC   AND    COSMETIC    SURGERY 

Furrow  About  Canthus 

Deficiency  of  Ocular  Stump 

(  Bil 


(  Unilateral. 
I  Bilateral. 

Unilateral. 

Bilateral. 


DEFORMITIES  ABOUT  THE  CHIN 
Anterior  Mental  Deficiency 


Partial. 
Total. 

(  Unilateral. 
Lateral  Mental  or  Angular  Deficiency  -  „.,  A 

Bilateral. 


DEFORMITIES  ABOUT  THE  EAR 
Pro-auricular  Deficiency 
Post- auricular  Deficiency 


j  Unilateral. 
\  Bilateral. 
|  Unilateral. 
(  Bilateral. 


SPECIFIC     CLASSIFICATION     FOR     THE     EMPLOYMENT 

AND   INDICATION    OF    HYDROCARBON  PROTHESES 

ABOUT  THE   SHOULDERS,   ETC. 


Supraclavicular  Deficiency 

Infraclavicular  Deficiency 

Inter  clavicular  (Notch)  Deficiency. 

Supra-acromion  Deficiency 

Infra-acromion 
Supramammary  Deficiency 


Mammary  Deficiency 

Supraspinous  Deficiency 

Infraspinous  Deficiency 
Interscapular  Deficiency. 


f  Partial  ] 
[Total    ] 


Unilateral. 
Bilateral. 
Unilateral. 
Bilateral. 

Unilateral. 

Bilateral. 

Unilateral. 

Bilateral. 

Unilateral. 

Bilateral. 

Unilateral. 

Bilateral. 

Unilateral. 

Bilateral. 

Unilateral. 

Bilateral. 

Unilateral. 

Bilateral. 


HYDROCARBON    PEOTIIESES  279 


SPECIFIC   TECHNIQUE   FOR   THE   CORRECTION   OF 
REGIONAL   DEFORMITIES  ABOUT   THE   FACE 

TRANSVERSE  DEPRESSIONS 

Punctate  Form. — Such  deficiencies  are  either  of  sharply 
defined  depressions  in  a  part  of  the  frontal  bone  due  to 
congenital  malformation  or  of  traumatic  origin. 

In  the  first  instance  they  are  usually  unilateral  or 
median  and  rarely  ever  bilateral.  In  those  of  the  second 
class  the  deformity  may  be  median,  but  is  more  often 
found  to  be  unilateral. 

Linear  depressions  of  the  forehead  are  usually  found  to 
be  congenital,  although  traumatism  in  the  form  of  direct 
violence  may  be  the  cause,  as,  for  instance,  the  kick  from 
a  horse  or  a  severe  blow  or  fall. 

The  acquired  linear  form  of  lack  of  contour  is  found 
in  people  of  middle  life  given  to  undue  use  or  corruga- 
tion of  the  forehead,  as  in  frowning. 

The  correction  of  this  class  of  deformities  may  be 
accomplished  by  carefully  raising  the  depressed  area  by 
repeated  injections  of  small  quantities,  always  avoiding 
the  frontal  and  supra-orbital  vessels. 

At  no  time  should  such  a  deformity  be  corrected  in 
one  sitting,  unless  when  the  defect  is  a  congenital  one  of 
small  moment. 

The  reaction  following  these  injections,  owing  to  the 
close  attachment  of  the  integument  to  the  bone,  is  usually 
found  to  be  more  severe  than  where  the  skin  is  more 
loosely  attached. 

In  traumatic  cases  the  scar  attachments  should  be 
freely  liberated,  under  eucain  anesthesia,  by  the  aid  of  a 
fine  probe-pointed  tenotome,  before  the  cold  paraffin  mix- 
ture is  introduced. 

In  such  event  only  one  opening  should  be  made  and 
just  enough  of  the  mixture  be  injected  to  raise  the  skin 
to  its  normal  contour,  if  this  be  possible.  Generally,  later 


280     PLASTIC    AND    COSMETIC    SURGERY 

injections  are  required,  and  these  may  be  made  without 
further  dissection.  They  should  not  be  undertaken  until 
the  incised  wound  made  with  the  tenotome  has  healed 
thoroughly,  otherwise  the  pressure  of  the  injection  is 
liable  to  burst  through  the  delicately  healed  wound,  and 
thus  delay  if  not  endanger  the  success  of  the  first  opera- 
tion. 

When  the  reaction  following  such  injections  be  severe, 
associated  with  considerable  edema,  cold  pack  or  ice 
cloths  should  be  applied  or  resort  may  be  had  to  hot  ap- 
plications of  antiphlogistin.  '  The  patient  should  be  kept 
on  his  feet  during  the  day  and  sleep  with  the  head  high  at 
night.  The  bowels  should  be  kept  open,  and  general  ton- 
ics be  given  if  indicated.  The  patient  usually  returns  to 
the  normal,  except  for  a  little  tenderness  about  the  fore- 
head, in  three  or  four  days  under  the  treatment  outlined. 

DEFICIENT  OR  RECEDING  FOREHEAD 

In  this  condition  there  is  usually  a  transverse  lack  of 
contour  across  the  forehead  above  the  superciliary  ridges, 
giving  the  patient  a  degenerate  appearance.  The  defect 
is  congenital  and  is  to  be  corrected,  as  described  in  the 
foregoing  division,  although  the  injections  may  be  at 
either  outer  or  temporal  end  of  the  forehead,  gradually 
being  brought  nearer  to  the  median  line  until  the  contour 
of  the  whole  forehead  has  been  raised  by  subsequent  in- 
jections. 

UNILATERAL  DEFICIENCY 

This  defect  may  be  traumatic — the  result  of  direct 
violence,  but  is  more  commonly  due  to  a  frontal  sinus 
operation. 

In  both  events  it  will  be  found  necessary  to  detach  the 
cicatrices  that  bind  the  skin  down  to  the  injured  bone, 
before  a  prothetic  injection  may  be  undertaken. 

In  some  cases  where  the  cause  of  the  deformity  has 


HYDEOCAKBON  PEOTHESES      281 

been  moderate  and  the  scar  is  linear  and  of  long  stand- 
ing the  injection  may  be  undertaken  without  subcutane- 
ous dissection. 

Several  injections  are  necessary,  as  the  tissue  about 
such  parts  is  usually  much  thickened,  apart  from  the 
firmness  added  by  the  scar  tissue. 

A  short  stout  needle  should  be  employed,  the  puncture 
being  preferably  made  under  ethyl-chlorid  anesthesia,  as 
the  pressure  necessary  to  raise  the  tissue  causes  consid- 
erable pain. 

To  further  facilitate  the  injection  the  operator 
should  raise  the  skin  with  the  needle  introduced  sub- 
cutaneously. 

Only  one  injection  of  small  amount  (10  to  15  drops) 
should  be  done  at  a  sitting.  The  injected  mass,  unless  too 
easily  introduced,  and  thus  forming  a  tumefaction,  need 
not  be  molded  out,  since  the  pressure  of  the  skin  overly- 
ing it  will  accomplish  it  more  satisfactorily,  while  the 
pressure  required  in  molding  tends  only  to  press  out 
more  or  less  of  the  mass,  thus  lessening  the  benefit  of 
the  operation. 

A  second  sitting  must  be  undertaken  in  not  less  than 
one  week,  or  even  later,  if  a  subcutaneous  dissection  has 
been  done. 

The  secondary  treatment  should  be  followed  as  here- 
tofore described.  The  reaction,  for  even  a  small  injection 
in  these  cases,  is  usually  considerable. 

INTERCILIAKY  FURKOW 

This  deformity  is  usually  spoken  of  as  a  frown.  It 
may  be  said  to  be  congenital,  when  it  appears  in  early 
life,  but  is  commonly  acquired  through  the  habit  of 
frowning. 

The  furrow  may  be  a  simple  linear  one  or  made  up 
of  a  number  of  furrows.  The  author  has  been  called 
upon  to  correct  one  made  up  of  six  distinct  furrows. 


The  furrows  or  creases  radiate  upward  and  out- 
ward, conelike  from  a  point  beginning  at  the  root  of  the 
nose. 

In  the  correction  of  this  common  deformity  the  oper- 
ator is  tempted  to  overdo  the  fault  by  hyperinjection.  A 
single  furrow  is  readily  corrected  by  a  few  drops  of  the 
injection,  which  should  be  neatly  smoothed  out.  A  little 
of  the  mass  at  this  part  of  the  face  seems  to  accomplish 
considerable;  in  fact,  the  part  seems  overcorrected  for 
some  time  after  a  judicious  and  carefully  done  opera- 
tion, which  is  undoubtedly  due  to  the  active  reaction  that 
follows  such  cosmetic  procedure,  owing  to  the  close  prox- 
imity of  the  frontal  veins  and  those  of  the  venous  arch 
at  the  root  of  the  nose,  which  undergo  more  or  less  phle- 
bitis of  a  mild  type,  the  resultant  edema  depending  upon 
the  pressure  caused  by  the  mass  on  these  vessels.  The 
intimate  relation  and  anastomoses  of  the  latter  is  clearly 
shown  in  the  carefully  prepared  dissection  represented 
in  the  frontispiece. 

In  injecting,  the  needle  should  be  introduced  at  a 
point  directly  at  the  root  of  the  furrow  or  furrows — that 
is,  at  the  junction  of  the  forehead  with  the  nose. 

A  needle  one  inch  long  should  be  used,  taking  care 
not  to  puncture  any  of  the  veins  which  are  found  to  be 
very  differently  placed  in  various  patients.  If  blood 
flows  from  the  needle  puncture,  no  injection  should  be 
made  at  that  point,  but  another  be  chosen  which  does  not 
give  such  result,  preferably  at  a  later  sitting. 

The  needle  should  be  introduced  well  upward  under 
the  skin  so  that  its  point  corresponds  to  the  point  of 
greatest  depression. 

The  injection  should  be  made  slowly  and  continued 
until  a  tumor,  judged  to  be  sufficient  to  overcome  the 
major  deformity  when  molded  out  has  been  formed. 

This  knowledge  can  only  be  gained  by  experience,  and 
the  operator  must  be  cautioned  to  underinject  rather 
than  cause  undue  prominence  of  that  part  of  the  face, 


HYDROCARBON  PROTHESES      283 

If,  however,  his  judgment  has  not  been  accurate 
enough,  the  operator  can  immediately  thereafter  squeeze 
out  enough  of  the  filling  to  give  him  the  desired  correc- 
tion. 

If  more  than  a  single  furrow  is  to  be  corrected,  he 
may  inject  the  two  center  ones,  leaving  the  outer  for 
later  operation. 

In  multiple  furrows  the  injections  must  be  made  in 
conelike  form,  to  give  a  normal  contour  to  the  forehead. 
The  apex  of  such  cone  corresponding  to  a  point  at  the 
root  of  the  nose,  and  the  base  to  an  arc  with  its  greatest 
convexity  near  the  median  hair  line  of  the  scalp,  depend- 
ing upon  the  length  of  the  furrows. 

The  injections  in  such  cases  should  be  made  at  least 
three  days  apart,  two  being  made  at  each  sitting,  after 
the  central  or  two  inner  depressions  have  been  raised  by 
the  first  operations.  These  later  injections  should  be 
made  to  relieve  the  furrows  lying  next  to  the  median, 
gradually  working  out  to  each  slant  side  of  the  cone  until 
the  contour  of  the  middle  forehead  has  been  made  nor- 
mal. 

Never  superimpose  an  injection  about  the  median  line 
until  the  major  defect  in  general  has  been  overcome,  and 
only  then  when  the  first  injections  have  become  settled 
and  organized,  as  such  untimely  disturbance  is  liable  to 
set  up  considerable  reaction,  with  enough  induration  and 
resultant  new  connective-tissue  formation  to  cause  a  de- 
cided lumpy  or  protuberant  appearance  of  the  part. 

The  mixtures  of  low  melting  points  should  be  pre- 
ferred to  the  harder  variety  in  frown  corrections.  They 
lend  themselves  to  better  molding,  and  seem  to  undergo 
organization  with  less  pathological  change  than  those  of 
the  latter  class. 

When  the  injections  must  be  made  over  the  inner 
third  or  half  of  the  eyebrows,  as  is  often  the  case,  they 
should  be  made  well  above  the  hair  line  and  molded  out 
in  an  upward  direction,  to  avoid  the  dropping  down  of 


284      PLASTIC    AND    COSMETIC    SURGERY 

the  mass  into  the  upper  lids  or  to  prevent  the  resultant 
displacing  connective  tissue  from  involving  them. 

If  the  upper  lids  do  become  involved,  as  shown  by  full- 
ness, hardness,  and  partial  ptosis,  the  connective  tissue 
causing  the  same  must  be  carefully  cut  out  from  the  lid 
by  a  transverse  semicircular  incision  made  in  the  upper 
lid  along  the  line  of  its  backward  fold  or  hinge.  If  need 
be,  an  elliptical  strip  cf  the  skin  of  the  lid  may  be  re- 
moved at  the  same  time  to  give  better  scope  to  the  extir- 
pation under  consideration. 

The  author  has  recently  corrected  two  such  cases 
where  a  surgeon  had  hyperinjected  the  entire  forehead 
with  a  combination  of  oils  at  one  or  two  sittings.  The 
resultant  involvement  and  later  discoloration  of  the  lids 
at  the  end  of  a  year's  time  might  have  been  expected. 

Such  wounds,  when  neatly  sutured  with  No.  1  twisted 
silk,  leave  surprisingly  little  scars ;  in  fact,  the  cicatrices 
are  rarely  ever  detected  a  few  days  after  healing  has 
been  established. 

The  treatment  post-injectio  for  all  furrow  protheses 
should  be  as  already  laid  down. 

Apart  from  general  surgical  cleanliness  and  an  anti- 
septic powder,  the  blepharoplastic  operation  mentioned 
required  no  special  attention.  The  sutures  may  be  re- 
moved in  forty-eight  hours. 

TEMPORAL  MUSCULAR  DEFICIENCY 
Unilateral  and  Bilateral 

This  facial  defect  while  possibly  unilateral,  as  in 
hemiatrophy,  is  generally  met  with  in  the  bilateral  form 
due  to  either  hereditary  causes  or  a  lack  of  nourishment 
of  the  parts,  the  latter  usually  involving  the  greater 
part  of  the  face.  Chronic  diseases  and  the  cachexia 
dependent  upon  disease  may  be  the  origin,  in  which  the 
deformity  is  rarely  ever  overcome  entirely  by  internal 
treatment  and  massage  of  the  parts;  if  anything,  mas- 


285 

sage  tends  to  elongate  the  skin  about  the  temples,  caus- 
ing a  worse  disfigurement  in  the  form  of  numerous  fine 
furrows. 

The  correction  of  the  defect  under  consideration  may 
be  readily  overcome  by  repeated  and  careful  injections 
of  a  hydrocarbon  of  low  melting  point. 

The  author  prefers  the  use  of  sterilized  vaselin  in- 
jected in  its  cold  state.  The  use  of  paraffin  of  high  melt- 
ing points  or  its  compounds  is  not  advisable,  and  if  em- 
ployed leaves  the  temples  uneven  or  lumpy,  due  to  the 
unequal  organization  or  new  tissue  formation  caused 
thereby,  at  the  same  time  causing  sagging  of  the  skin  of 
the  adjacent  parts,  particularly  the  upper  eyelids,  owing 
to  the  added  weight  of  the  new  tissue  growth  occasioned 
by  such  preparations. 

Contrary  to  general  expectation,  this  part  of  the  face 
is  readily  injected  and  corrected. 

The  skin  should  be  pinched  up  with  the  thumb  and 
forefinger  of  the  left  hand  and  the  needle  introduced  with 
the  right  hand  in  such  way  as  to  exclude  the  puncturing 
of  blood  vessels. 

To  assure  the  operator  against  such  difficulty  the 
needle  may  be  withdrawn  after  insertion,  and  if  blood 
does  not  trickle  from  the  wound  it  may  be  reintroduced 
without  pain  to  the  patient  and  the  injection  begun. 

It  is  not  advisable  to  correct  the  defect  at  one  sitting. 
One  third  or  one  half  of  the  depressed  area  may  be  over- 
come by  one  injection.  The  resultant  tumefaction  must 
then  be  thoroughly  molded  out,  until  little  seems  to  have 
been  accomplished  by  the  injection. 

The  operator  trusts  in  these  particular  cases  more  to 
the  development  of  new  connective  tissue  than  in  any 
other  part  of  the  face,  except  perhaps  in  the  correction  of 
an  interciliary  furrow.  It  is  surprising  how  much  is  at- 
tained by  the  most  conservative  injections  in  and  about 
the  temples. 

The  molding  of  the  injected  mass  must  be  done  in  a 


286     PLASTIC   AND    COSMETIC    SURGERY 

superio-posterior  direction  to  avoid  forcing  it  into  the 
upper  eyelids,  resulting  in  the  same  overdevelopment 
previously  referred  to. 

Both  temples  should  be  injected  as  advised  at  one  sit- 
ting. The  use  of  the  ethyl-chlorid  spray  makes  the  oper- 
ation less  fearful  to  the  patient. 

Subsequent  injections  should  not  be  done  earlier  than 
three  weeks  or  until  any  discoloration  of  the  skin  of  the 
parts  has  disappeared.  The  latter  is  not  an  unusual 
occurrence,  and  is  undoubtedly  due  to  the  pressure  of  the 
injected  mass  upon  the  numerous  blood  vessels  found 
there. 

The  post-operative  treatment  should  be  followed  as 
heretofore  advocated. 


DEFORMITIES  OF  THE  NOSE 

The  use  of  hydrocarbon  protheses  for  the  correction 
of  nasal  deformities  has  revolutionized,  to  a  great  extent, 
the  rhinoplasty  of  many  centuries.  Through  their  em- 
ployment many  unsatisfactory  cutting  operations  have 
been  entirely  displaced,  and  it  is  quite  right  to  hold  that 
the  introduction  of  other  subcutaneous  protheses  and  like 
apparatuses  of  amber,  celluloid,  caoutchouc,  silver,  gold, 
aluminium,  ivory,  or  other  nature  have  been  supplanted 
by  this  method  of  operation,  when  these  were  needed  to 
correct  a  partial  deformity  of  the  nose. 

When  a  total  rhinoplasty  has  to  be  undertaken  the 
paraffin  group  of  protheses  of  course  cannot  be  resorted 
to,  owing  to  a  lack  of  the  necessary  retentive  walls  of 
tissue,  except  perhaps  in  such  cases  where  the  so-called 
double  flap,  or  French  method,  is  employed,  and  there 
only  after  the  parts  have  become  thoroughly  organized. 

A  somewhat  complete  tabulation  of  nasal  defects  has 
been  given  heretofore  which  gives  an  excellent  idea  of 
the  extensive  use  these  hydrocarbon  injections  may  be 
put  to. 


HYDROCARBON    PROTIIESES  287 

Such  nasal  deformities  as  are  amenable  to  this  method 
of  correction  may  be  due  to  either  congenital  causes, 
lack  of  development,  direct  violence,  ulcerative  changes 
following  catarrh,  syphilis,  and  tubercular  disease.  In 
some  cases,  however,  the  defects  are  purely  of  a  cosmetic 
nature,  and  not  considered  as  abnormalities  except  by 
the  critical  eye  of  the  patient.  This  is  true  particularly 
with  lobular  and  supra-alar  deficiencies,  as  well  as  a 
slight  lack  of  contour  about  the  anterior  line. 

In  some  instances  the  defect  may  be  an  acquired  one, 
as  in  the  lateral  deviation  known  as  handkerchief  bend. 

A  specific  and  somewhat  elaborate  classification  has 
been  given  to  the  more  important  and  distinctive  deform- 
ities of  the  nose,  principally  to  facilitate  the  proper  cita- 
ton  and  recording  of  cases. 

It  may  be  readily  understood  that  each*  one  of  these 
classifications  may  be  further  subdivided,  but  such  sub- 
division can  be  only  of  the  degree  or  extent  of  the  deform- 
ity, and  must  be  left  to  the  individual  operator  and  his 
thoroughness  of  observation  and  nicety  of  recording. 

The  author  prefers  making  a  plaster  cast  of  the  entire 
nose  which  is  to  be  corrected,  and  a  second  cast  after  the 
operation  has  been  completed,  or  at  the  time  of  his  dis- 
charge. A  record  sheet,  or  a  direct  photograph,  can 
be  made  before  and  after  operation  for  the  same  pur- 
pose, which  is  not  so  desirable,  however,  because  it  has 
been  found  quite  impossible  to  procure  the  desired  accu- 
rate pictures  of  a  nasal  deformity,  the  photographer  not 
being  given  to  bringing  out  imperfections  as  the  sur- 
geon wishes  them,  even  under  the  most  explicit  instruc- 
tions, unless  the  surgeon  accompanies  the  patient  to  the 
studio  to  supervise  the  posing.  This  requires  a  waste 
of  valuable  time ;  not  to  speak  of  the  expense  of  making 
pictures  of  a  pathological  nature.  The  better  way  would 
be  to  have  an  apparatus  in  the  operating  room.  The 
surgeon  can  then  pose  his  patient  against  a  screen  back- 
ground in  the  position  and  to  the  size  of  picture  he  may 


288     PLASTIC    AND    COSMETIC    SUEGERY 

desire.  Plate  cameras  and  time  exposures  are  best  for 
this  purpose.  For  recording  and  half -tone  reproduction 
silver  prints  are  found  best. 

For  all  deformities  of  the  anterior  nasal  line  a  hydro- 
carbon compound  of  the  higher  melting  points  should  be 
used.  This  should  be  injected  in  the  cold  form.  The 
mixture  given  on  page  39,  with  perhaps  an  added  half 
dram  or  dram  of  paraffin,  has  been  found  excellent,  the 
addition  of  paraffin  being  made  to  assure  a  suitable 
fineness  of  contour  and  width.  The  softer  mixtures  are 
more  liable  to  cause  a  lack  of  contour  and  a  consequent 
widening  of  the  part  injected,  even  after  molding,  be- 
cause of  the  contractility  of  the  skin  overlying  the  in- 
jected mass,  which  tends  to  flatten  it  out,  giving  the  nose 
a  less  artistic  and  delicate  appearance. 

Furthermore,  a  soft  mixture  will  be  found  to  be  ineffi- 
cient in  overcoming  the  tension  of  the  skin  in  most  cases, 
especially  those  about  the  middle  third  of  the  nose. 

In  some  cases  of  lateral  deformity,  and  where  other- 
wise mentioned,  it  is  advisable  to  use  only  a  mixture  of 
the  lower  melting  points,  as  in  the  case  in  the  correction 
of  interciliary  furrows  and  temporal  muscular  deficiency. 

Superior  Third  Deficiency. — The  degree  of  depression 
about  the  superior  third  or  root  of  the  nose  varies  con- 
siderably. The  most  extensive  form  may  be  commonly 
found  in  the  negro  nose,  where  there  is  almost  an  ab- 
sence of  a  rise  in  that  part  of  the  nasal  bones.  Such 
noses  are  also  found  in  the  Chinese  and  Japanese.  The 
condition  ofttimes  may  be  associated  with  epicanthus. 

Epicanthus,  formerly  corrected  by  an  elliptical  exci- 
sion done  anteriorly,  can  be  entirely  overcome  by  the 
subcutaneous  injection  method,  thus  not  only  avoiding 
the  resultant  linear  cicatrix,  but  building  up  the  de- 
pressed nose  to  its  normal  contour. 

The  skin  overlying  most  of  the  defects  of  the  supe- 
rior third  is  usually  found  to  be  loose,  hence  injection  is 
readily  accomplished. 


289 


290     PLASTIC    AND    COSMETIC    SURGERY 

The  needle  should  be  introduced  laterally  and  ante- 
rior to  the  angular  vessels  to  prevent  their  occlusion  and 
injection.  The  point  of  selection  is  made  at  about  the 
middle  of  the  deformity.  The  needle  is  introduced  until 
its  point  lies  in  the  center  of  the  depression,  or  at  the 
median  line  from  the  anterior  view. 

The  mass  is  injected  slowly  as  the  skin  of  the  nose  is 
pinched  up  between  the  forefinger  and  thumb  of  an  as- 
sistant. 

The  part  is  injected  until  a  tumefaction,  equal  in  body 
to  the  extent  of  the  deformity,  is  attained. 

The  needle  is  allowed  to  remain  in  place  for  a  mo- 
ment, to  permit  of  a  stoppage  of  the  thieadlike  mass, 
usually  following  the  pressure  applied  to  the  piston,  after 
the  operator  has  stopped  turning  the  screw.  This  will 
prevent  the  mass  from  following  into  the  channel  made 
by  the  needle,  or  the  backing  up  of  the  mass,  as  it  were. 
Should  this  occur  the  paraffin  mixture  should  be  squeezed 
from  the  skin  opening  to  prevent  the  formation  of  an 
intercutaneous  encystment. 

Immediately  the  needle  is  withdrawn  the  operator 
places  a  finger  tip  over  the  opening  and  proceeds  with 
the  thumb  and  forefinger  of  the  right  hand  to  mold  the 
mass  into  the  desired  shape. 

The  post-operative  treatment  should  be  as  previously 
given,  and  is  the  same  with  all  injections  about  the  nose, 
so  that  it  will  not  be  referred  to  again  under  this  heading. 

While  a  fairly  large  defect  can  be  corrected  at  one  sit- 
ting, it  is  advisable  to  rather  reinject  one  or  two  weeks 
later  to  secure  the  exact  shape. 

It  is  to  be  impressed  upon  the  operator  that  there  is 
always  a  slight  broadening  of  this  part  of  the  nose  fol- 
lowing the  development  of  the  connective  tissue  which 
takes  the  place  of  the  injected  mass,  hence  the  injection 
should  not  be  overcrowded  nor  the  parts  overcorrected. 

The  mass  should  be  molded  out  as  narrow  as  possible 
and  be  pinched  between  the  fingers  by  the  patient  two 


HYDROCARBON  PROTHESES      291 

or  three  times  a  day  after  the  reaction  has  subsided, 
which  is  usually  about  the  third  day.  This  procedure 
will  keep  the  mass  from  being  flattened  during  the  time 
tissue  replacement  takes  place. 

Middle  Third  Deficiency. — This  defect  is  commonly  seen 
in  football  players  and  pugilists  as  the  result  of  a  break- 
ing of  the  inferior  extremities  of  the  nasal  bones  and  the 
displacement  of  the  articulating  cartilages,  although  the 
defect  is  often  seen  as  a  result  of  an  injury  to  the  nose 
early  in  life,  causing  a  lack  of  development  in  the  supe- 
rior or  articulating  extremities  of  the  cartilages.  Non- 
development  from  catarrh,  syphilis,  and  intranasal  dis- 
ease are  other  causes.  This  type  of  deformity  is  gener- 
ally designated  as  the  saddle  nose. 

In  the  latter  cases  the  skin  is  usually  bound  down  to 
the  cartilaginous  structure  by  cicatricial  bands,  and  needs 
to  be  liberated.  This  is  accomplished  subcutaneously 
with  a  fine  tenotome  introduced  laterally. 

To  assure  the  operator  of  a  thorough  dissection  he 
may  inject  the  site  with  sterile  water  through  the  open- 
ing made  with  the  knife,  squeezing  it  out  before  inject- 
ing the  nose. 

If  the  skin  has  had  to  be  freed  by  surgical  means  the 
mass  injected  should  be  sufficient  to  overcome  the  defect 
almost  entirely,  to  prevent  the  reformation  of  the  bands 
of  connective  tissue  which  have  been  severed.  Their  re- 
establishment  would  mean  an  unequal  development  of 
the  new  connective  tissue  springing  up  from  the  injected 
mass,  thus  defeating  the  object  of  the  operation. 

If  no  dissection  has  been  done  the  defect  should  be 
corrected  about  two  thirds  and  added  to  by  a  subsequent 
injection. 

The  mass  in  either  case  should  be  well  molded  out, 
especially  at  both  sides,  to  keep  the  nose  as  narrow  as 
possible.  There  will  be  more  or  less  widening  ultimately 
following  the  organization  of  the  mass. 

It  is  not  uncommon  to  find  a  dividing  wall  of  subcu- 


292 


HYDKOCAKBON  PEQTHESES      293 

taneous  tissue  about  the  articulation  of  the  nasal  bones 
and  cartilages,  as  evidenced  by  a  rising  up  or  down  of 
the  injected  mass  above  or  below  this  line.  If  this  be 
found,  rather  than  break  down  this  wall  with  the  injec- 
tion, it  is  deemed  advisable  to  inject  each  chamber  sepa- 
rately and  mold  the  two  masses  after  injection,  as  in  the 
ordinary  type  of  cases. 

Inferior  Third  Deficiency. — This  deformity  of  the  nose  is 
due  purely  to  a  lack  of  development  or  a  luxation  of  the 
cartilage  of  the  septum  and  the  upper  lateral  cartilages. 
The  point  or  lobule  of  the  nose  is  usually  tilted  upward 
and  the  subseptum  curved  upward  at  its  middle  third. 

The  cause  of  this  deformity  is  usually  due  to  direct 
violence  at  some  time  in  life,  with  improper  replacement 
at  the  time  of  injury.  Syphilis  and  intranasal  catarrh, 
lupus  and  ulcerative  diseases,  are  also  causes. 

The  skin  overlying  the  defect  may  or  may  not  be 
closely  adherent,  but  is  in  most  cases  rather  thickened 
and  inelastic.  It  is  therefore  necessary,  in  most  cases, 
to  loosen  the  skin  by  subcutaneous  dissection,  done  as 
already  described  before  the  injection  is  made. 

To  rebuild  such  a  nasal  defect  without  dissection,  ex- 
cept in  such  instances  where  the  skin  is  quite  elastic,  is 
not  to  be  advised,  since  the  injected  mass  would  be  flat- 
tened, more  or  less,  antero-posteriorly,  giving  the  nose  a 
broad  and  ugly  appearance  after  the  connective-tissue 
formation  has  been  attained. 

It  is  with  cases  of  this  kind  that  paraffin  injections 
introduced  in  the  liquid  form  and  of  high  melting  points 
are  usually  expelled  in  a  week  or  ten  days,  or  even  later, 
subsequent  to  a  breaking  down  of  the  surrounding  tissues 
and  the  resultant  abscess. 

The  best  preparation  to  employ  is  the  form  of  paraf- 
fin mixture  advocated  in  the  preceding  operation  used  in 
its  cold  state  and  injected  slowly,  after  the  integument 
has  been  rendered  mobile  enough  to  permit  the  desirable 
correction. 


294 


HYDROCARBON  PROTHESES      295 

The  defect  should  not  be  corrected  in  one  sitting,  for 
the  very  reason  that  some  widening  of  the  nose  may  take 
place,  owing  to  the  contractility  of  the  skin,  post-operatio. 

The  mass  injected  should  correct  the  major  part  of 
the  defect  and  be  molded  out  carefully,  especially  from 
both  sides  of  the  nose,  and  the  patient  be  instructed  to 
pinch  the  nose  laterally  several  times  a  day  after  the 
reactive  inflammation  has  subsided  with  the  object  of 
keeping  the  nose  as  narrow  as  possible. 

After  the  mass  has  been  thoroughly  replaced  with 
connective  tissue  and  the  anterior  line  is  found  to  be  too 
depressed,  a  fine  line  of  the  mass  about  the  thickness  of 
the  needle  may  be  injected  over  it  in  a  vertical  direction, 
the  point  of  a  fairly  large  needle  being  introduced  just 
above  the  anterior  aspect  of  the  lobule  and  thrust  up- 
ward to  the  superior  border  of  the  now  existing  deform- 
ity, and  be  slowly  withdrawn  as  the  mass  is  injected. 

This  will  leave  a  rounded  cylindrical-like  mass  along 
the  anterior  nasal  line,  which  must  not  be  molded  at  all, 
except  to  soften  or  shade  off  the  superior  and  inferior 
extremities. 

The  author  advocates  making  two  such  injections, 
at  the  same  sitting,  when  the  deformity  has  persisted. 
These  injections  are  made  parallel  to  each  other  with  a 
distance  of  about  one  eighth  inch  between  them. 

The  subseptal  deficiency  will  also  have  to  be  cor- 
rected. This  will  be  referred  to  later  under  its  separate 
division. 

The  reaction  in  cases  of  this  type  is  usually  more 
severe  than  those  just  mentioned.  There  may  be  con- 
siderable swelling  and  discoloration,  but  by  following  the 
methods  of  treatment  laid  down  heretofore  the  symptoms 
usually  subside  in  two  or  three  days. 

Superior  Half  Deficiency.  — In  this  type  of  deformity  there 
is  found  a  nondevelopment  of  the  bridge  of  the  nose, 
while  the  greater  part  of  the  cartilage  of  the  septum  and 
the  lower  lateral  cartilages  seem  to  be  quite  normal  in 


contour.  The  nose  has  a  dished  appearance,  with  an  un- 
due prominence  of  the  nasal  base  or  lower  half. 

Various  causes  may  be  given  to  this  condition,  but 
heredity  is  responsible  in  a  great  majority  of  the  cases. 

The  deformity  in  the  type  under  consideration  rarely 
takes  in  an  accurate  half  of  the  nose,  there  being  an  in- 
volvement more  or  less  of  the  lower  anterior  half,  yet  it 
is  sufficiently  distinctive  to  give  it  specific  classification. 

For  the  correction  of  the  defect  in  such  cases  the  in- 
jection is  made  laterally,  the  same  mass  being  employed 
as  in  the  preceding  cases. 

In  this  type  of  case  the  mass  injected  should  quite 
correct  the  defect  and  be  molded  with  great  care  to  a 
desired  contour,  keeping  in  mind  always  the  condition 
and  elasticity  of  the  skin  overlying  it. 

An  inflexible  skin  should  be  rendered  mobile  by  digi- 
tal massage,  practiced  for  a  few  days  prior  to  operation, 
or  in  tense  conditions  be  loosened  by  subcutaneous  dis- 
section. 

The  great  fault  in  injecting  so  large  a  quantity  as 
is  necessary  in  these  cases  is  to  make  the  nose  too  wide 
from  the  very  beginning,  which,  added  to  the  widening 
following  the  replacement  by  new  tissue,  makes  the  shape 
of  the  nose  unsatisfactory. 

For  this  reason  it  will  be  found  of  some  benefit  to 
apply  an  anterior  nasal  splint  of  aluminium,  covered  in- 
teriorly with  a  fold  of  white  flannel  or  gauze  and  pressed 
into  such  shape  that  when  applied  to  the  nose  it  will 
keep  the  latter  pinched  up  laterally  to  the  desired  width. 
This  splint  will  hardly  ever  be  borne  by  a  patient  and 
causes  great  discomfort  until  after  the  post-operative 
reaction  has  subsided.  It  may  then  be  bandaged  or  held 
in  place  by  strips  of  Z.  0.  Adhesive  plaster  for  an  hour 
or  two  in  the  day  and  during  the  entire  night. 

After  the  first  few  days'  wearing  the  patient  soon  be- 
comes accustomed  to  the  splint.  It  should  be  worn  as 
mentioned  for  about  three  weeks,  when  the  patient  may 


HYDROCARBON  PBOTHESES      297 

be  permitted  to  pinch  the  nose  laterally  with  his  fingers 
two  or  three  times  a  week  or  more. 

The  secondary  injection  may  be  made  in  the  ordinary 
way  or  as  advocated  by  the  author  in  the  manner  de- 
scribed in  correcting  defects  of  the  inferior  third  of  the 
nose. 

Inferior  Half  Deficiency. — In  this  type  of  deformity  the 
greater  point  of  nondevelopment  or  deficiency  is  found 
at  the  upper  extremity  of  the  cartilage  of  the  septum, 
below  its  articulation  with  the  inferior  border  of  the 
nasal  bones,  and  involving  to  a  greater  extent  the  area 
over  the  upper  lateral  cartilages. 

This  deformity,  due  to  whatever  cause,  rarely  affects 
the  base  or  inferior  part  of  the  nose,  owing  undoubtedly 
to  the  greater  protection  and  stability  offered  by  the 
lower  lateral  and  sesamoid  cartilages  and  the  dense  cellu- 
lar tissue  making  up  the  alae.  Except  in  such  cases  where 
violence  of  an  extreme  nature  has  been  exerted  in  early 
life,  or  where  ulcerative  disease  has  broken  down  most 
of  the  cartilage  of  the  septum,  the  point  of  the  nose  is 
usually  normal  in  size  and  shape.  In  the  latter  cases 
there  is  an  upper  tilt  of  the  lobule  and  a  shortening  of 
the  calumna  upon  itself  with  a  convexity  in  an  upward 
direction. 

The  cause  of  this  type  of  deformity  is  usually  a  direct 
blow  upon  the  point  of  the  nose,  syphilitic  ulceration  in- 
ternally, catarrh,  or  other  ulcerative  disease. 

When  due  to  violence  the  point  of  the  nose  may  or 
may  not  present  a  normal  appearance,  there  may  be  a 
normal  base  tilted  upward  (retrousse  or  snout  nose)  or 
a  dropping  forward  and  downward  (hook  or  beak  nose). 

The  shape  of  the  nasal  base  depends  much  upon  the 
time  of  life  the  injury  was  received — that  is,  before  or 
long  after  puberty,  also  upon  the  extent  of  injury  in- 
flicted and  where  applied. 

From  injuries-  received  early  in  life  we  may  look  to 
a  lack  of  development  in  the  cartilage  of  the  septum 


298      PLASTIC    AND    COSMETIC    SURGERY 

alone,  or  associated  with  deficiency  in  one  or  both  lateral 
cartilages. 

The  deformity  is  usually  symmetrical,  but  where  the 
nasal  bones  have  been  injured  as  well,  particularly 
where  one  bone  is  injured  more  than  its  fellow,  there  is  a 
possibility  of  the  disfigurement  being  unilateral.  This  is 
rarely  the  case  except  when  due  to  punctured  wounds; 
generally  in  such  cases  the  anterior  nasal  line  assumes 
a  twisted  form. 

Some  operators  have  included  noses  of  undue  lobular 
prominence  (a  la  Cyrano  de  Bergerac)  under  this  type 
of  deformity,  and  while  it  is  to  be  admitted  such  a  nose 
might  be  built  up  by  subcutaneous  prothesis  the  result 
is  anything  but  harmonious  or  normal.  Such  a  nose 
should  be  reduced  by  cutting  operations  instead  of  being 
added  to.  The  seeming  depression  above  the  lobule  is 
only  comparative  to  the  overdeveloped  form  of  the  lob- 
ule. The  face  values  of  every  patient  should  be  studied, 
and  the  surgeon  should  never  attempt  to  break  up  the 
harmony  of  facial  form  by  simplifying  an  operation  and 
rendering  the  patient's  appearance  even  more  ridiculous 
than  before  his  attempt  to  correct  a  fault. 

The  correction  of  the  deficiencies  of  the  lower  half 
of  the  nose  is  associated  with  difficulties  in  various  direc- 
tions. Either  the  skin  over  the  defect  is  too  dense  to 
render  injection  an  easy  matter,  or  the  nose  is  so  broad- 
ened horizontally  from  the  original  injury  that  the  injec- 
tion, no  matter  how  artistically  done,  leaves  the  nose 
bulky  and  ugly  in  appearance. 

When  the  nasal  processes  of  the  superior  maxillary 
bones  have  not  been  widened  unduly  by  an  injury  and 
the  skin  is  dense,  simple  subcutaneous  dissection  before 
injection  will  overcome  the  difficulty  easily  enough. 

In  that  case  the  needle  is  inserted  laterally  in  a  line 
with  the  maximum  depth  of  the  depression  and  the  point 
shoved  up  to  the  median  line  anteriorly. 

Enough  of  the  cold  mixture  of  paraffin  and  vaselin,  as 


HYDROCARBON  PROTHESES      299 

heretofore  advised,  is  injected  to  reduce  the  deformity 
nearly  to  the  normal. 

The  mass  is  molded  to  give  the  nose  as  near  a  normal 
contour  as  possible,  always  keeping  in  mind  the  later 
broadening  of  the  nose  when  the  new  connective  tissue 
has  taken  the  place  of  the  injected  mass.  A  later  injec- 
tion made,  as  advised  heretofore,  will  restore  the  ante- 
rior line  to  better  form. 

If  the  nasal  processes  of  the  superior  maxillary  bones 
have  been  thrown  outward  considerably  a  surgical  oper- 
ation is  necessary  to  reduce  them. 

No  injection  should  be  made  until  the  wounds  from 
such  operation  are  thoroughly  healed  and  contracted. 

In  all  cases  of  this  type  the  skin  will  be  found  to  be 
rather  dense  and  likely  to  be  tied  down  by  past  inflam- 
mations to  the  anterior  aspects  of  the  lower  lateral  carti- 
lages at  their  juncture  with  the  upper  lateral  cartilages. 
If  the  adhesions  are  not  too  dense  the  harder  form  of 
the  cold  mixture  should  be  used.  This  will  not  only  per- 
mit of  raising  the  skin  more  readily  than  with  a  softer 
kind  of  mixture,  but  will  be  more  likely  to  retain  its  form 
under  the  contractile  pressure  brought  to  bear  down 
upon  it. 

When  the  skin  is  closely  adherent  it  should  be  loos- 
ened subcutaneously,  as  already  advised.  The  injection 
may  be  done  at  the  same  sitting,  and  be  of  greater  quan- 
tity than  in  the  cases  where  this  had  not  been  done,  for 
the  reasons  mentioned. 

Pressure  splints  and  manual  compression  should  be 
employed  as  in  the  preceding  deformity. 

The  reaction  following  the  first  injection  is  likely  to 
be  severe.  Cold  applications,  as  previously  referred  to, 
are  indicated,  and  should  be  continued  for  at  least  two 
days. 

Care  should  be  taken  not  to  inject  into  the  lateral  ves- 
sels, which  usually  lie  on  a  line  with  the  juncture  between 
the  lateral  and  lower  lateral  cartilages.  If  this  should 


300      PLASTIC    AND    COSMETIC    SURGERY 

happen,  the  point  of  the  nose  at  once  assumes  a  bluish 
hue,  and  there  is  more  or  less  pain  felt  at  once,  with  con- 
siderable swelling  a  few  hours  after  the  injection.  Later, 
every  symptom  of  gangrene  of  the  lobule  is  liable  to  be 
noticed,  yet  with  faithful  attention  to  furthering  the 
circulation  of  the  parts  by  either  cold  or  hot  applications, 
the  active  inflammatory  symptoms  usually  subside  in 
ten  to  fourteen  days,  leaving  the  patient  with  a  whole 
nose,  more  or  less  colored  at  the  lobule,  according  to  the 
state  of  the  circulation  and  the  exposure  of  the  parts  to 
the  various  temperatures.  This  may  be  overcome  in  time, 
yet  it  may  persist  for  years,  depending  entirely  upon  the 
ability  of  the  anastomosing  vessels  to  overcome  the  arti- 
ficial thrombus  or  occlusion  offered  by  the  mass  injected. 

That  a  reaction  quite  similar  in  character,  but  of 
milder  degree,  is  likely  to  be  seen  when  one  of  these  ves- 
sels has  not  been  injected,  can  be  readily  understood 
when  we  consider  that  a  hard  and  somewhat  ungiving 
mass  is  made  to  overlie  the  vessels  themselves.  The 
symptoms  just  described  in  such  case  are  apt  to  be  noted 
much  later,  even  several  hours  after  the  injection,  be- 
cause the  swelling  has  then  begun  to  add  its  pressure  to 
that  of  the  mass  in  obstructing  the  flow  of  blood  to  the 
lobule.  Such  condition  may  be  termed  pressure  occlu- 
sion in  contradistinction  to  thrombotic  obstruction. 

These  symptoms  usually  subside  in  a  day  or  two,  or 
with  the  swelling  caused  by  the  reaction. 

If  the  symptoms  appear  at  once  after  the  injection, 
it  is  best  to  force  out  as  much  of  the  injected  mass  as  is 
possible  through  the  needle  hole  through  which  it  has 
been  introduced. 

The  author  was  called  to  attend  a  case  several  hours 
after  the  operator  had  injected  a  nose.  The  acute  symp- 
toms pointed  to  a  direct  occlusion  of  the  vessels,  yet  the 
surgeon  who  had  performed  the  operation  assured  me  he 
had  not  injected  until  he  found  that  blood  did  not  flow 
from  the  needle  after  its  insertion.  To  relieve  the  pa- 


301 


302      PLASTIC    AND    COSMETIC    SURGERY 

tient  of  immediate  fright  and  some  pain,  a  dull  pointed 
needle  of  larger  caliber  than  the  one  used  in  operation 
was  pushed  through  the  needle  wound  previously  made, 
taking  the  place  of  a  cannula,  and  a  greater  part  of  the 
injected  mass  was  squeezed  out.  Ice  cloth  applications 
were  followed  through  the  night  and  the  nose  recovered 
in  three  days  without  showing  the  discoloration  of  the 
skin  usually  observed  following  such  cases.  The  nose 
was  never  injected  again,  on  account  of  the  dread  of  the 
patient,  but  peculiarly  the  anterior  line  showed  almost 
a  normal  contour  after  four  weeks  had  elapsed.  This 
only  goes  to  prove  that  very  much  less  of  the  mass  to 
be  injected  is  required  than  is  commonly  supposed  by 
operators. 

Total  Anterior  Deficiency. — In  this  condition  there  is  a 
scooped-out  or  general  curved-in  appearance  of  the  en- 
tire anterior  nasal  line.  The  lobule  of  the  nose  is  usually 
normal  in  size. 

This  defect  should  be  corrected  by  two  injections  of 
the  paraffin  compound  previously  referred  to.  The 
points  of  injection  should  be  lateral  and  anterior  to  the 
angular  vessel  on  the  side  of  the  nose  preferred  by  the 
operator — one  about  the  center  or  major  curvature  and 
the  other  about  the  inferior  third. 

Care  should  be  taken  to  mold  the  injected  mass  as 
narrow  as  possible,  or  as  much  as  the  skin  will  permit. 
If  the  latter  is  bound  down  it  should  be  mobilized  by 
subcutaneous  dissection  or  levation.  A  subsequent  in- 
jection should  not  be  undertaken  until  the  entire  mass  has 
become  settled  or  fairly  organized,  which  is  about  the 
end  of  three  weeks. 

The  mass  should  be  injected  well  up  to  the  root  of 
the  nose  to  give  it  the  appearance  of  the  normal  bridge. 
If  this  is  found  impossible  owing  to  a  dividing  skin  at- 
tachment, a  third  needle  puncture  should  be  made  at  a 
point  on  a  level  with  the  internal  canthus. 

Care  must  be  exercised  to  keep  the  mass  from  creep- 


303 


304     PLASTIC   AND    COSMETIC    SURGERY 

ing  into  the  loose  tissue  about  the  internal  canthi  by  hav- 
ing an  assistant  press  the  sides  of  the  nose  at  that  point 
with  the  thumb  and  forefinger. 

This  undesirable  condition  is  much  more  liable  to 
occur  when  a  hot  liquid  paraffin  is  employed,  since  the 
operator  can  observe  quite  accurately  the  extent  and  di- 
rection taken  by  the  mass  injected  when  the  cold  product 
is  used. 

Some  authorities  have  injected  noses  of  this  type 
from  the  point  of  the  nose,  but  it  will  be  found  that  the 
position  of  the  puncture  at  this  point  allows  a  consider- 
able portion  of  the  mass  to  work  out  during  molding 
and  also  to  permit  of  the  readier  oozing  out  of  the  mass 
during  the  pressure  exerted  by  what  reactive  inflamma- 
tion follows  the  operation.  This  is  accounted  for  by 
the  fact  that  the  needle  creates  a  tubelike  canal  in  the 
tightly  bound  down  tissue  overlying  the  lower  lateral 
cartilages,  whereas  in  the  lateral  punctures  the  short 
canal  is  easily  displaced  by  the  swelling,  thus  causing 
its  obliteration  and  preventing  the  free  oozing. 

On  the  other  hand,  it  will  be  found  to  be  more  difficult 
to  inject  from  the  point  of  the  nose  alone  and  that  a 
very  long  needle  has  to  be  used  which  must  be  with- 
drawn as  the  parts  above  the  point  are  filled.  Further- 
more, it  will  be  found  necessary  to  thrust  the  point  of 
the  needle  in  different  directions  to  overcome  vertical 
attachments  of  the  skin  which  are  more  readily  lifted 
up  than  thrust  aside  by  the  mass,  hence  necessitating  a 
greater  amount  of  injury  to  the  tissues,  not  to  speak 
of  the  possibility  of  injecting  transverse  blood  vessels 
higher  up  in  the  nose  of  which  the  operator  would  not 
be  aware  at  the  time ;  showing  only  in  the  resultant  phle- 
bitis and  unexpected  reactive  symptoms,  associated  with 
a  discoloration  more  or  less  lasting  according  to  the  ex- 
tent of  obliteration  of  the  vessels. 

The  post-operative  treatment  should  be  as  heretofore 
advised. 


HYDROCARBON  PROTHESES      305 

Lateral  Insufficiency  (Unilateral  and  Bilateral). — De- 
pressions about  the  sides  of  the  nose  are  usually  due  to 
hereditary  causes,  when  they  are  likely  to  be  bilateral, 
yet  intranasal  ulcerations  may  cause  a  falling-in,  as  it 
were,  of  either  one  or  both  nasal  walls,  involving  in  such 
instances  the  entire  side  or  part  of  it.  In  the  partial 
cases  the  depression  may  be  in  any  of  the  division  of 
thirds  used  by  the  author — that  is,  it  may  lie  laterally 
over  the  region  of  the  nasal  bone  and  such  of  the  nasal 
process  of  the  superior  maxillary  bone  as  goes  to  make 
up  that  part  of  the  nose,  or  in  the  middle  third  below  the 
bone  structure  and  above  the  superior  limitation  of  the 
lower  lateral  cartilages,  or  within  the  lower  third  over 
the  inferior  border  of  the  cellular  tissue  making  up  the 
nasal  rim. 

Traumatism  may  be  found  to  be  the  cause  of  such 
depressions,  especially  in  the  middle  third,  after  fracture 
or  luxation  of  the  nose.  In  such  cases  the  defect  is  usu- 
ally unilateral  or  at  the  seat  of  the  former  injury,  a  con- 
vexity usually  being  exhibited  on  the  opposite  side. 

Since  the  skin  is  rather  firmly  adherent  at  the  sides 
of  the  nose,  except  in  the  major  part  of  the  superior 
third,  it  will  be  found  best  to  raise  the  skin  of  such  de- 
fect into  normal  contour  by  a  series  of  very  small  injec- 
tions instead  of  following  the  method  heretofore  advised 
in  connection  with  tense  or  adherent  areas  of  skin,  for 
the  reason  that  such  dissection  would  render  the  skin  too 
mobile  over  an  area  usually  beyond  the  defect  itself  and 
inviting  the  surgeon  to  an  annoying  hyperinjection  which 
renders  the  part  more  unsightly  than  prior  to  the  opera- 
tion. This  is  true  in  most  cases  unless  the  depression  is 
of  traumatic  origin  and  beyond  the  size  of  deformity 
usually  corrected. 

The  author  advocates  the  employment  of  a  hypoder- 
mic needle  attached  to  the  syringe  in  place  of  the  regular 
needle  and  that  the  injection  be  of  sterile  white  vaselin 

without  additions  of  any  kind. 
21 


306     PLASTIC   AND    COSMETIC    SURGERY 

Such  injections  may  be  made  very  readily,  one  or 
more  at  the  first  sitting,  being  introduced  below  the  deep- 
est part  of  the  defect.  It  is  surprising  how  much  four 
or  five  drops  of  such  an  injection  will  accomplish.  Fur- 
thermore, it  is  to  be  remembered  that  the  injections 
about  the  side  of  the  nose  are  readily  replaced  by  new 
connective  tissue,  equal  to,  if  not  commonly  greater  in 
amount,  than  the  mass  injected,  such  growth  being  com- 
pleted in  about  two  months  after  the  time  of  injection. 
This  may  be  explained  by  a  more  or  less  active  peri- 
chondritis  when  the  injection  is  made  over  the  cartilage, 
the  inflammation,  thus  set  up,  being  of  longer  duration 
than  where  the  skin  and  bone  or  areolar  tissue  are  in- 
volved. Any  subsequent  injection  should  not  be  under- 
taken until  at  the  end  of  two  weeks  or  more  for  the  rea- 
sons above  stated. 

The  injected  mass  at  all  times  should  be  introduced 
under  normal  pressure,  never  to  the  extent  of  rendering 
the  skin  above  it  white  in  color.  The  mass  should  also 
be  molded  out  with  the  tip  of  the  finger  or  the  rounded, 
dull  handle  end  of  a  scalpel.  If  necessary,  the  small  fin- 
ger may  be  introduced  into  the  nostril  to  facilitate  this 
molding.  Should  the  reactive  inflammation  be  severe 
such  remedial  agents  as  have  been  referred  to  should  be 
used  to  reduce  it. 

Phlebitis  following  injections  at  the  side  of  the  nose 
is  due  entirely  to  the  injection  of  a  blood  vessel  and  must 
be  avoided.  When  a  fine  needle  is  used  there  is  less  like- 
lihood of  free  bleeding  from  an  injured  vessel,  therefore 
a  thorough  knowledge  of  the  usual  position  of  the  vessels 
about  the  sides  of  the  nose  is  absolutely  essential.  Bleed- 
ing of  greater  extent  than  that  which  would  follow  the 
thrust  of  the  needle  through  the  skin  should  put  the  sur- 
geon on  his  guard.  Experience  is  the  better  teacher 
and  conservatism  in  these  ofttimes  delicate,  subcuta- 
neous operations  will  save  the  surgeon  much  annoy- 
ance and  eventually  the  need  of  having  the  patient 


HYDBOCARBON  PROTHESES      307 

submit  to  a  cutting  operation  to  reduce  an  overcorrected 
area. 

Should  a  hyperplasia  of  connective  tissue  result  from 
such  an  operation,  a  small  linear  incision,  under  four 
per  cent  eucain  anesthesia,  should  be  made  directly  over 
the  greatest  prominence,  through  which  the  offending 
mass  can  be  removed  by  the  aid  of  a  small  hooked  knife 
or  a  fine  pair  of  curved  scissors. 

The  mass  should  be  removed  beyond  the  plane  of  the 
skin ;  in  fact,  it  should  be  rather  removed  in  conelike  form, 
apex  inward,  and  the  peripheral  attachment  completely 
obliterated,  in  order  to  obtain  the  desired  result,  as  it  is 
not  unusual  to  have  the  prominence  reappear  after  im- 
perfect extirpation  and  improper  dissection. 

Moist  pressure  dressings  may  be  applied  over  the 
small  wound  thus  made,  for  several  days,  or  until  the 
inflammation  following  the  operation  has  subsided.  Su- 
turing such  a  wound  is  hardly  necessary,  but  if  the  in- 
cision be  over  one  fourth  of  an  inch  long,  two  fine  silk 
sutures,  deeply  placed,  may  be  utilized,  their  tension 
adding  to  the  compression  needed  to  bring  the  mobilized 
skin  into  position  in  reference  to  the  base  of  the  wound. 

The  author  has  used  contractile  collodion  in  place  of 
compress  dressings  with  very  good  result.  This  should 
be  renewed  within  forty-eight  hours. 

After  eight  or  ten  days  silk  isinglass  adhesive  plaster 
is  applied  over  the  wound  until  it  falls  off. 

Lobular  Insufficiency. — This  defect  of  the  nose  is  usually 
of  hereditary  origin,  although  it  may  be  occasioned  by 
the  retraction  of  the  inferior  half  of  the  organ  in  tuber- 
cular or  syphilitic  ulceration  in  which  the  lobule  falls  in- 
ward and  upward  by  the  loss  of  the  retaining  cartilages. 

Owing  to  the  close  adhesion  of  the  skin  to  the  lower 
lateral  cartilages  and  the  cellular  tissue  about  the  rim  of 
the  ate  it  is  found  difficult  to  restore  the  contour  or  elon- 
gate the  organ  at  that  site  by  subcutaneous  injection. 

Even  after  thorough  mobilization  of  the  integument 


308     PLASTIC    AND    COSMETIC    SUEGEEY 

the  subsequent  injected  mass  is  liable  to  be  thrown  off 
l>y  an  overactive  inflammatory  reaction,  due  undoubtedly 
to  the  adhesions  formed  between  the  divided  surfaces 
from  the  periphery  inward  which  has  a  tendency  to 
crowd  the  injected  mass  forward  and  downward  before 
a  new  connective  tissue  has  had  time  to  be  formed,  caus- 
ing a  breaking  down  of  the  skin  at  some  point  overlying 
the  mass  and  allowing  it  to  escape. 

The  author  has  attempted  to  replace  the  injection  by 
small  solid  paraffin  plates  introduced  through  a  small 
lateral  incision  made  for  the  subcutaneous  dissection,  and 
while  the  wound  healed  readily  enough  and  the  nose  ap- 
peared normal,  the  plates  were  in  every  case  thrown  off 
by  a  later  inflammatory  process  before  the  end  of  the 
third  week. 

The  author  then  attempted  to  replace  the  solid  plates 
with  granular  paraffin,  gently  packing  the  latter  into 
the  wound  until  the  desired  elevation  had  been  obtained 
with  the  idea  that  such  mass  would  accommodate  itself 
much  better  under  the  pressure  caused  by  reactive  in- 
flammation, but  even  this  procedure  proved  unsuccessful. 

The  best  results  are  obtained  with  sterilized  white 
vaselin  injections  when  there  is  considerable  mobility 
of  the  skin.  A  single  needle  opening  should  be  made, 
preferably  about  the  center  of  the  side  of  the  lobule,  or 
slightly  anterior  to  this  point,  carrying  the  point  of  the 
needle  forward  to  the  anterior  median  line  and  a  little 
above  the  actual  point  of  the  nose. 

The  injection  should  be  made  slowly,  closely  watch- 
ing the  size  of  the  elevation  caused  by  the  mass  and  the 
state  of  the  circulation  about  the  entire  lobule. 

Usually  ten  drops  of  the  mass  suffice  to  give  the  de- 
sired result.  The  mass  may  be  molded  out  if  found 
desirable,  but  if  the  skin  appears  normal  after  the  opera- 
tion and  the  tumefaction  thus  made  does  not  make  the 
nose  look  grotesque,  it  may  be  allowed  to  remain  as  in- 
jected, depending  upon  the  subsequent  reactive  pressure 


HYDROCARBON  PROTHESES      309 

to  force  it  into  shape.  In  this  way  a  greater  part  of  the 
mass  is  retained  at  the  wanted  site  and  is  not  crowded 
to  the  sides  of  the  lobule  by  the  customary  post-operative 
molding. 

Even  with  this  method  great  care  must  be  exercised 
in  not  injecting  too  much  at  each  sitting.  A  failure  is 
sure  to  result  in  hyperinjection  about  the  lobule.  When 
it  be  remembered  that  only  a  very  small  quantity  of  the 
mass  will  make  a  decided  difference,  the  surgeon  and 
patient  should  be  satisfied  with  the  slightest  gain. 

If,  however,  the  mass  be  retained  and  further  elonga- 
tion of  the  lobule  is  desired,  a  subsequent  injection  can 
be  undertaken,  but  not  until  a  full  month  after  the  pri- 
mary operation. 

Here,  as  with  lateral  nasal  injections,  there  seems  to 
be  an  overproduction  of  new  connective  tissue  following 
such  an  injection;  a  decided  factor  in  eventually  pleasing 
the  patient. 

It  is  needless  to  say  that  the  operator  must  avoid  in- 
jecting one  of  the  blood  vessels  of  the  lobule,  as  this  will 
cause  considerable  inflammation  from  which  the  lobule 
does  not  recover  readily,  owing  to  the  dense  tissue  the 
surgeon  has  to  deal  with,  leaving  the  tip  of  the  nose  dis- 
colored and  bluish  for  some  time  after  the  operation. 

If  the  injected  mass  causes  an  immediate  venous 
stasis  of  the  lobule,  hot  applications  should  be  applied  at 
once,  or  as  soon  as  the  operator  discovers  that  the  proper 
massage  and  pressure  to  remove  the  offending  mass  does 
not  improve  the  circulation. 

The  author  advocates  the  judicious  use  of  antiphlo- 
gistin,  faithfully  applied  hot  every  six  hours  and  con- 
tinued until  the  acute  inflammatory  symptoms  subside, 
when  the  surgeon  may  resort  to  ice  cloths  or  cold  pack 
until  the  danger  of  pressure  and  resultant  gangrene  have 
subsided. 

Despite  the  very  grave  symptoms  associated  with  such 
inflammation,  the  operator  may  assure  the  patient  against 


310     PLASTIC   AND    COSMETIC    SURGERY 

permanent  disfigurement,  although  the  three  or  four 
weeks'  duration  of  treatment,  usually  required  in  such 
cases,  is  an  ordeal  the  cosmetic  surgeon  and  the  patient 
are  not  liable  to  forget. 

If  the  injected  mass  causing  this  state  of  affairs  has 
been  of  liquid  paraffin,  the  better  method  to  pursue  is 
to  make  several  small  incisions  into  the  site  of  the  injec- 
tions and  remove  the  little  masses  of  solid  paraffin  as 
far  as  possible  with  the  view  of  relieving  the  pressure 
or  encroachment,  at  the  same  time  alleviating  the  pain 
and  stasis  by  the  resultant  depletion.  Moist,  hot  appli- 
cations should  follow  this  procedure.  The  small  wounds 
made  in  the  skin  will  heal  without  suture,  leaving  hardly 
any  perceptible  scar. 

The  author,  however,  advises  against  any  mixture  or 
liquid  paraffin  injections  about  the  lobule,  never  having 
seen  a  satisfactory  result  when  either  had  been  employed. 

The  post-operative  treatment  in  uncomplicated  cases 
may  be  of  aristol  and  adhesive  isinglass  plaster  or  col- 
lodion. 

Interlobular  Deficiency. — This  condition  is  hereditary  in 
the  great  majority  of  cases.  The  defect,  while  quite  dis- 
figuring, giving  the  appearance  of  a  cleft  nasal  point,  is 
easily  corrected  by  the  subcutaneous  injection  method. 

Paraffins  of  high  melting  points  should,  however, 
never  be  employed  for  this  purpose  for  diverse  reasons : 
first,  the  hardening  of  the  mass  after  cooling  causes  too 
much  pressure  upon  the  small  blood  vessels  at  the  point 
of  the  nose  and  results  in  more  or  less  permanent  dis- 
coloration of  the  tip;  second,  by  reason  of  the  pressure 
of  a  hard  mass,  at  the  end  of  the  nose,  considerable  in- 
flammation results  which  usually  terminates  in  the  evacu- 
ation of  the  entire  mass  and  consequent  cicatrization; 
third,  by  virtue  of  the  greater  irritating  qualities  of 
paraffin  a  greater  amount  of  new  connective  tissue  than 
necessary  is  thrown  out,  causing  a  general  and  hyper- 
plastic  rounding  of  the  entire  tip  of  the  nose  that  re- 


HYDROCARBON  PROTHESES      311 

quires  surgical  interference  to  overcome.  In  the  illus- 
tration shown  the  patient's  nose  was  injected  along  the 
entire  anterior  line  and  the  lobule  with  paraffin  liquefied 


FIG.  301. — UNTOWABD  EFFECT  OF  PARAFFIN  INJECTION  ABOUT  LOBULE  AND 
ANTERIOR  NASAL  LINE.  Scar  lines  on  nose  indicate  the  various  attempts 
made  to  reduce  the  resultant  hyperplasia. 

under  heat.  A  marked  post-operative  inflammation  re- 
sulted, with  permanent  redness  of  the  entire  organ  and 
several  decisive  capillaries  showing  about  the  sides  and 
tip  of  the  nose.  This  was  followed  in  about  six  weeks 
by  a  progressive  hyperplasia  which  left  the  nose  about 
three  times  its  natural  size,  and  the  lobule  a  hard,  ball- 
like  knob  of  high  red  color.  Several  cosmetic  operations 
were  required  to  make  the  nose  appear  anywhere  near 
normal,  while  the  electrolytic  needling  process  was  re- 
sorted to  for  a  number  of  sittings  to  destroy  the  acute 
redness  and  the  individual  vessels  showing. 


312     PLASTIC    AND    COSMETIC    SURGERY 

While  a  great  many  workers  with  paraffin  deny  any 
beneficial  results  from  the  employment  of  sterile  white 
vaselin  for  subcutaneous  injections,  the  author  claims 
that  in  this  particular  class  of  deformity  it  is  almost  ex- 
clusively required. 

The  vaselin  in  cold  state  should  be  injected  directly 
under  the  skin  overlying  the  deepest  point  of  the  cleft 
and  be  slowly  continued  until  the  lobule  assumes  its  nor- 
mal contour.  The  puncture  may  be  made  below  the 
point  of  the  nose. 

One  such  injection  usually  suffices  to  correct  the  fault. 
The  reactive  symptoms  are  not  severe  if  proper  technic 
has  been  applied,  and  cold  compresses  usually  relieve  it 
within  twenty-four  hours. 

Should  the  skin  be  adherent  about  the  anterior  aspect 
of  the  lower  lateral  cartilages,  it  can  be  forced  away  with 
a  small,  dull,  round-pointed  knife  resembling  an  eye  spud, 
the  opening  for  which  need  not  necessarily  be  greater 
than  that  made  for  the  needle.  The  latter  is  inserted 
through  the  same  opening,  which  must  be  closed  over  in 
this  event  with  a  drop  of  contractile  collodion  into  which 
aristol  is  introduced  with  the  pulverflator,  which  not  only 
embodies  an  antiseptic,  but  at  the  same  time  hastens  its 
hardening. 

Alar  Deficiency  (Unilateral  and  Bilateral). — The  con- 
traction about  the  nasal  rims  may  be  due  to  hereditary 
causes  or  the  result  of  intranasal  disease.  The  defect  is 
usually  bilateral,  involving  the  entire  alae  or  only  their 
lower  half  or  third. 

The  fault  should  be  corrected  by  several  injections 
made  along  the  rim  of  the  nasal  whig,  using  a  fine  needle, 
preferably  of  the  hypodermic  size.  Vaselin  only  should 
be  used  and  two  or  three  drops,  according  to  the  extent 
of  the  deformity,  be  injected  into  the  cellular  tissue  at 
the  point  of  each  needle  insertion. 

Three  of  such  punctures  may  be  made  along  the  rim, 
one  beyond  the  other  in  each  wing.  According  to  the 


HYDROCARBON  PROTHESES      313 

defect  the  injection  may  be  carried  higher  or  lower  above 
the  margin  of  the  rim  by  shoving  the  needle  upward  and 
toward  the  inferior  border  of  the  lower  lateral  cartilage. 

The  reaction  in  these  cases  is  very  little,  rarely  neces- 
sitating other  than  an  antiseptic  powder-plaster  dress- 
ing. Subsequent  injections  should  be  made  if  the  first 
do  not  give  the  desired  contour ;  but  never  until  the  sur- 
geon is  satisfied  that  the  resultant  new  connective  tissue 
thrown  out  has  reached  its  ultimate  growth. 

The  harder  paraffins,  especially  those  injected  in  the 
liquefied  state,  are  not  to  be  tolerated  for  the  reasons 
given  with  the  preceding  method  of  correction. 

Subseptal  Deficiency  (Partial  and  Complete). — It  is  not 
uncommon  to  find  a  marked  concavity  of  the  subseptum 
in  noses  that  have  sunken  in  by  reason  of  intranasal  dis- 
ease or  traumatism. 

This  concavity,  when  partial,  is  usually  most  marked 
near  the  lobule,  but  in  the  complete  variety  the  upward 
curve  may  be  greatest  near  its  juncture  with  the  lip. 

Owing  to  the  usual  adhesions  formed  during  the  in- 
flammatory period  causing  the  deformity  the  correction 
of  this  defect  is  quite  difficult.  As  a  rule,  the  skin  of  the 
entire  subseptum  needs  to  be  dissected  away  from  the 
underlying  structure  before  it  will  permit  of  correction 
by  the  injection  method. 

This  dissection  is  advocated  and  can  be  readily  done 
from  one  of  the  nostrils  at  a  point  just  beyond  the  union 
of  skin  and  mucous  membrane. 

The  dissection  under  such  method  can  be  made  more 
thoroughly  than  when  done  exteriorly,  for  the  reason 
that  the  entire  field  is  laid  open  to  a  free  use  of  the 
scalpel,  leaving  no  visible  cicatrix  externally.  The  dis- 
section may  be  followed  by  the  immediate  injection  of 
the  mixture  of  paraffin  and  vaselin,  as  already  referred 
to,  used  cold,  or  the  area  is  injected  with  normal  salt 
solution  until  the  intranasal  wound  has  healed,  which 
usually  takes  place  in  about  five  days.  The  mucous  mem- 


314      PLASTIC    AND    COSMETIC    SURGERY 

brane  in  such  instance  may  be  neatly  but  not  too  tightly 
sutured  with  No.  1  silk.  If  the  operator  deems  it  ad- 
visable he  may  inject  the  salt  solution  again  on  the  third 
day  to  prevent  the  formation  of  such  adhesions  as  may 
interfere  with  the  ultimate  hydrocarbon  injection.  This 
is  rarely  found  necessary. 

If  the  post-operative  inflammation  prove  mild,  then 
the  adhesions  will  not  be  as  tenacious,  in  which  case  the 
surgeon  may  wait  until  even  the  seventh  or  eighth  day 
before  injecting  the  paraffin  compound,  to  be  sure  of  not 
forcing  the  intranasal  wound  apart  under  the  pressure 
of  the  mass  injected. 

Never  should  so  large  a  quantity  of  the  mass  be  in- 
jected as  to  cause  blanching  of  the  narrow  strip  of  skin. 
This  is  sure  to  result  in  gangrene  of  some,  if  not  all,  of 
the  skin  of  the  subseptum — a  result  much  to  be  regretted, 
since  subsequent  correction  of  the  deformity  increased 
by  the  contraction  of  the  dermal  cicatrix  is  rendered  well- 
nigh  impossible  by  reason  of  this  very  tissue. 

Hard  paraffin  injected  in  its  molten  state  is  never 
borne  in  this  part  of  the  human  economy.  It  is  usually 
thrown  off  after  a  few  days  of  very  painful  and  highly 
inflammatory  symptoms,  undoubtedly  explained  by  the 
fact  that  the  circulation  of  the  subseptum  is  principally 
dependent  upon  the  delicate  branches  of  the  two  small 
septal  arteries  of  the  superior  coronary  and  a  hard,  un- 
giving  mass  would  readily  cause  their  obliteration. 

DEFORMITIES  ABOUT  THE  MOUTH 

Labial  Deficiency  (Upper  and  Lower  Lip). — There  are  a 
number  of  causes  creating  deficiencies  about  the  labial 
orifice.  The  same  causes  apply  naturally  to  both  lips, 
whether  the  defect  be  unilateral,  bilateral,  or  median. 
Some  of  these  deformities  are  more  often  met  with  than 
others,  as,  for  instance,  a  median  deficiency  of  the  upper 
lip  following  cicatricial  contraction  due  to  a  harelip  op- 


HYDKOOAEBON  PBOTHESES      315 

eration  done  early  in  life;  in  elderly  patients  a  partial 
paralysis  is  found  to  affect  one  half  the  upper  and  some- 
times a  part  of  the  lower  lip,  giving  to  the  mouth  a 
drooped  and  grinning  appearance. 

Other  causes  are  dental  defects,  abnormalities  of  the 
alveolar  processes,  traumatism,  and  disease. 

In  those  conditions  where  loss  of  tissue  is  responsible 
for  the  defect,  as  in  the  extirpation  of  neoplasms,  ulcera- 
tive  disease,  etc.,  it  is  quite  likely  that  cheiloplasty  is 
required  to  rebuild  the  parts,  but  in  many  of  these  cases 
splendid  results  may  be  obtained  by  the  judicious  use  of 
hydrocarbon  protheses  to  overcome  the  usual  post-opera- 
tive oral  distortion.  It  is  understood  that  such  injections 
should  not  be  undertaken  until  the  wounds  are  thoroughly 
healed  and  the  cicatricial  union  fully  contracted.  This  is 
true  also  in  harelip  operations  undertaken  later  in  life. 

The  correction  of  labial  defects  coming  under  this 
method  is  not  at  all  difficult,  but  artistic  skill  and  judg- 
ment are  as  necessary  as  the  surgical  technic. 

The  lips  are  plentifully  supplied  with  blood  vessels, 
and  therefore  greater  care  in  injecting  a  foreign  mass 
into  their  structure  is  necessary;  furthermore,  the  lips 
cannot  be  placed  at  rest  for  any  long  period  of  time, 
so  that  the  mass  injected  can  never  be  expected  to 
be  kept  in  place  if  of  a  consistency  hard  enough  to  per- 
mit the  contraction  of  the  orbicularis  muscle  to  move 
it  about. 

From  the  very  fact  of  this  practically  constant  move- 
ment of  a  part  it  is  self-evident  such  hard  mass  could 
not  be  retained  or  held  in  position  for  any  length  of  time, 
unless  the  mass  is  small  enough  not  to  be  affected  by 
the  movement,  and  under  such  condition  the  correction 
of  a  defect  as  desired  by  the  patient  would  require  per- 
haps months  to  accomplish,  owing  to  the  very  fact  that 
only  droplike  masses  may  be  deposited  under  the  skin  in 
perhaps  a  half  dozen  places  with  the  necessity  of  a  long 
period  of  rest  until  the  injections  have  been  replaced  by 


316      PLASTIC    AND    COSMETIC    SURGERY 

the  new  tissue  before  the  next  operation  could  be  under- 
taken. 

It  is  absolutely  absurd  to  think  of  injecting  a  lip 
with  hard  paraffin  liquefied  by  heat  and  expect  to  obtain 
a  satisfactory  result.  While  it  is  true  the  mass  is  mold- 
able  immediately  after  its  introduction,  so  that  a  desired 
shape  may  be  obtained,  it  does  not  overcome  the  fact, 
however,  that  the  mass  must  harden,  as  it  will,  and  that, 
while  a  part  of  it  is  broken  away,  as  it  were,  from  the 
mass  proper,  there  is  a  nuclear  contraction  as  the  hard- 
ening takes  place,  thus  overcoming  partly  the  molded 
form ;  furthermore,  the  movement  of  the  parts  here  tends 
to  displace  the  mass.  Unequal  muscular  contraction 
breaks  up  not  only  the  form  but  also  the  mass  itself,  dur- 
ing all  of  which  time  it  is  made  to  act  as  an  irritant  by 
virtue  of  the  movement  of  the  uneven  edges  of  the  par- 
affin upon  the  adjacent  tissue. 

Furthermore,  the  presence  of  paraffin  and  the  result- 
ant mass  of  new  and  hard  connective  tissue,  so  well  rec- 
ognized by  all  experienced  surgeons,  is  not  desirable  in 
the  lip  structure ;  it  makes  the  lip  appear  bulky  and  hard 
and  anything  but  natural. 

It  is  in  these  very  cases  that  the  injections  of  cold 
sterile  white  vaselin  is  indicated.  After  injection  the 
mass  may  be  evenly  and  satisfactorily  molded  out,  the 
mass  being  soft  and  readily  pressed  into  shape  in  the 
various  cells  of  areolar  tissue  without  leaving  hard  and 
uneven  lumps. 

The  movement  of  the  lip  is  not  then  a  source  of  dan- 
ger in  displacing  the  mass,  since  the  acute  swelling  of 
the  lip  tissue  prevents  its  free  movement  for  several 
days,  which  gives  the  injected  mass  an  opportunity  to 
establish  itself  and  find  its  proper  place. 

Another  advantage  in  using  this  preparation  subcu- 
taneously  is  that  it  is  less  irritating  than  hard  paraffin, 
permits  freer  movement,  and  creates  a  better  production 
of  new  connective  tissue. 


HYDROCARBON  PROTHESES      317 

While  a  part  of  the  mass  may  be  absorbed  during  the 
replacement  period  the  lip  retains  its  normal  consistency, 
and  if  the  desired  contour  has  not  been  attained  a  subse- 
quent injection  may  be  made  in  three  weeks'  time  with- 
out interfering  in  any  way  with  the  former  result. 

The  only  precaution,  aside  from  avoiding  the  injec- 
tion of  blood  vessels,  is  to  keep  the  injection  from  the 
prolabium  or  vermilion  border.  The  latter  tissue  is  very 
prone  to  fatty  degeneration  or  to  yellowish  discolora- 
tions  when  such  a  foreign  mass  has  been  introduced  into 
or  near  its  structure. 

There  is  no  objection  in  injecting  the  lip,  upper  or 
lower,  in  several  places,  as  the  cellular  network  about 
the  mouth  is  sufficiently  dense  to  prevent  the  escape  of 
the  vaselin  injected  from  the  adjacent  opening  if  the  dis- 
tance is  not  less  than  a  half  inch  between  the  punctures. 

The  injections  may  be  made  from  above  downward  in 
the  upper  lip  and,  vice  versa,  in  the  lower.  They  should 
be  begun  at  the  outer  angle  working  toward  the  median 
line. 

The  reaction  following  such  an  injection  is  usually 
more  severe  than  in  any  other  tissue  of  the  face,  owing 
to  the  great  number  of  fine  blood  vessels,  but  the  swell- 
ing is  readily  controlled  in  two  or  three  days  by  cold 
applications. 

Aristol  collodion  dressings  over  each  wound  suffice  to 
close  the  punctures. 

In  the  median  variety  of  defect,  where  a  cicatricial 
band  separates  the  lip  into  halves,  it  may  be  found  nec- 
essary to  do  a  subcutaneous  dissection  before  a  suitable 
injection  can  be  done,  but  in  cases  of  long  standing  the 
dividing  wall  is  exceedingly  thin  and  the  threadlike  ad- 
hesions below  are  quite  easily  broken  up  by  the  force  of 
the  injection.  The  later  product  of  new  connective  tissue 
will  tend  to  further  improve  the  contour. 

Nasolabial  Furrows  (Unilateral  and  Bilateral). — This 
condition  in  the  bilateral  form  is  exceedingly  common  in 


318     PLASTIC   AND    COSMETIC    SUEGERY 

adults  beyond  middle  age.  It  is  also  found  in  those  indi- 
viduals suffering  from  inanition,  due  to  whatever  cause. 
The  unilateral  form  is  found  principally  in  patients  suf- 
fering from  semifacial  paralysis  in  which  the  tissue  lack- 
ing the  proper  neurotic  supply  droops  or  sags  down, 
causing  a  deep  furrow  to  appear  from  the  attachment  of 
the  ala3  to  the  angle  of  the  mouth,  associated  more  or  less 
by  a  flattening  of  the  cheek  contour  of  that  side  of  the 
face. 

The  method  of  correction  advocated  by  the  author 
varies  entirely  from  the  technic  advanced  by  other  sur- 
geons. 

The  usual  method  has  been  to  introduce  the  needle 
of  the  syringe  at  the  outer  or  lower  extremity  of  the 
furrow  and  from  one  of  such  punctures  to  inject  the 
whole  line  of  depression. 

While  this  seems  right  theoretically  the  method  does 
not  give  the  desired  result.  Owing  to  the  free  movement 
of  the  upper  lip  the  mass,  at  first  neatly  restoring  the 
contour,  is  crowded  upward  into  the  inferior  malar  re- 
gion and  very  often  downward  toward  the  angle  of  the 
mouth,  where  it  settles  in  a  hard  lump  which  is  not  only 
obnoxious  to  the  sight  but  interferes  with  the  proper  use 
of  the  parts  concerned  in  mastication  and  vocalization. 
Invariably  the  operator  is  called  upon  to  remove  the 
disfigurement. 

It  can  be  readily  understood  that  hard  paraffin  itself, 
in  such  case,  would  prove  more  objectionable  than  a 
softer  mass  which,  upon  early  discovery,  could  be  molded 
or  massaged  into  better  position,  while  nothing  less  than 
excision  would  prove  efficacious  with  paraffin. 

As  with  the  lip,  then,  the  author  advocates  the  use 
of  either  the  cold  mixture  of  paraffin,  as  heretofore  de- 
scribed, or  the  cold  white  vaselin  according  to  the  op- 
erator's opinion  in  overcoming  the  extent  of  the  fault. 
For  all  ordinary  cases  white  vaselin  alone  is  neces- 
sary. 


319 

The  technic  of  injection  as  used  by  the  author  is  as 
follows :  In  the  ordinary  case  when  the  furrow  is  not  too 
pronounced  one  sitting-  only  is  required.  Two  needle 
punctures  are  made  above  the  upper  line  of  the  defect, 
the  first  being  made  about  one  half  inch  from  the  wing 
of  the  nose  and  the  other  about  one  inch  outward  and 
downward. 

The  needle  is  pushed  downward  under  the  skin  until 
its  opening  corresponds  to  the  median  line  or  deepest 
part  of  the  furrow.  Enough  cold  white  vaselin  is  in- 
jected to  bring  the  depressed  area  slightly  above  the 
plane  of  the  skin  of  the  upper  lip.  The  second  puncture 
is  made  perpendicular  to  the  first  and  the  injection  made 
in  the  same  manner. 

With  the  tip  of  the  indicis  over  the  first  needle  open- 
ing the  mass  is  molded  out  evenly  by  a  gentle  rocking 
or  rubbing  movement.  The  same  is  done  with  the  sec- 
ond mass. 

It  will  be  found,  then,  that  the  two  masses  are  made 
to  meet  at  about  the  center  of  the  furrow,  leaving  a 
slight  wall  of  tissue  between  them.  This  wall  has  the 
virtue  of  preventing  the  falling  down  of  the  upper  mass, 
at  the  same  time  dividing  the  quantity  of  the  injected 
mass  into  two,  and  lessening  the  weight. 

If  the  condition  is  bilateral  both  sides  are  operated 
on  at  the  same  sitting.  If  subsequent  injections  are 
needed  they  are  done  three  weeks  later,  the  punctures 
being  made  between  the  former  first  and  second  punc- 
tures and  the  second  and  outer  border  of  the  furrow. 
In  this  way  the  entire  site  is  filled  with  a  series  of  in- 
jections. 

If  the  surgeon  desires  he  may  increase  the  number 
of  these  needle  punctures  at  the  first  sitting,  making 
them  nearer  together  in  that  event. 

It  will  be  found  necessary  in  some  cases  to  inject  the 
cold  mixture  of  vaselin  and  paraffin  into  the  furrow  di- 
rectly below  the  wing  of  the  nose,  since  the  integument 


320     PLASTIC   AND    COSMETIC    SURGERY 

at  that  point  requires  a  mass  somewhat  harder  than 
vaselin  to  force  and  hold  it  up. 

The  rest  of  the  furrow  must,  however,  be  injected 
with  vaselin  alone,  for  the  reasons  already  given  in  parts 
that  are  movable. 

The  reaction  is  rarely  very  marked  and  subsides  in 
about  three  days. 

Gentle  massage  may  be  permitted  above  the  site  of 
injection  to  keep  the  mass  from  crawling  into  the  cheek. 
This  is  done  by  gently  stroking  the  skin  from  below  up- 
ward toward  the  nose  on  a  line  an  inch  above  the  original 
depression. 

The  dressings  are  the  same  as  before  mentioned, 
although  collodion  painted  over  the  needle  openings  is 
most  serviceable  after  having  sponged  off  the  sites  with 
absorbent  cotton  dipped  into  absolute  alcohol  to  remove 
the  vaselin  that  may  have  exuded  from  the  openings  dur- 
ing the  molding-out  process. 

Oral-Angular  Furrow. — These  furrows  occur  at  the  cor- 
ners of  the  mouth,  running  downward  upon  the  anterior 
chin.  Small  as  these  defects  appear,  they  are  found  dif- 
ficult of  obliteration,  for  the  reason  that  the  tissues  are 
more  or  less  under  constant  movement  during  the  waking 
hours.  Repeated  injections,  each  of  small  quantity,  are 
necessary.  Hard  paraffin  is  contraindicated. 

The  injections  are  made  from  above  the  defect  down- 
ward at  right  angles  to  the  defect. 

It  will  be  found  difficult  to  keep  the  mass  from  being 
expelled  on  account  of  the  movement,  there  being  more 
or  less  oozing  from  the  puncture,  but  if  the  openings  can 
be  controlled  for  at  least  twenty-four  hours  this  danger 
may  be  overcome  to  a  great  extent. 

Ethyl  chlorid  may  be  sprayed  over  the  part  immedi- 
ately the  needle  is  withdrawn  to  set  the  mass  and  fol- 
lowed with  a  drop  of  collodion.  The  patient  is  advised 
to  keep  the  mouth  as  immovable  as  possible  for  the  rest 
of  the  day. 


321 

The  reaction  is  never  severe,  and  is  easily  controlled 
by  cold  applications.  If,  after  one  week,  there  is  shown 
a  tendency  to  sagging  of  the  mass,  it  should  be  gently 
massaged  upward  with  the  finger  several  times  during 
the  day  for  at  least  two  weeks ;  this  will  keep  it  in  place, 
and  allow  nature  to  replace  it  with  new  connective  tissue 
when  desired. 

DEFORMITIES  ABOUT  THE  CHEEKS 

Deficiency  of  Cheek  (Total  and  Partial). — A  total  lack 
of  proper  contour  of  the  cheek,  generally  termed  flatten- 
ing, may  be  due  to  hereditary  causes,  but  is  generally 
dependent  upon  a  cachexia  due  to  a  general  disease,  or 
fatty  degeneration  of  the  muscular  structure  of  the 
cheeks,  as  found  in  those  beyond  middle  age. 

A  partial  deficiency  of  the  cheek  or  cheeks  is  usually 
hereditary,  but  may  be  dependent  upon  digestive  disor- 
ders or  other  causes  of  malnutrition. 

This  class  of  deformity  is  found  more  often  in  women 
than  men.  It  is  usually  bilateral. 

Unilateral  cheek  deficiency,  whether  partial  or  total, 
may  be  congenital,  but  is  often  the  result  of  a  local  pa- 
ralysis causing  hemiatrophy.  Traumatisms  early  in  life 
or  during  birth  and  amputation  of  the  inferior  maxillary 
are  other  causes. 

This  class  of  deformity  is  quite  readily  corrected  by 
subcutaneous  injection;  in  fact,  it  is  the  only  known 
method  of  merit,  superseding  the  former  resort  to  partial 
correction  by  massage  or  artificial  and  temporary  correc- 
tion by  the  wearing  of  plumpers  in  the  buccal  cavity. 

The  method  of  procedure  is  the  same  in  all  cases,  the 
number  of  injections  and  quantity  varying,  of  course, 
with  the  extent  of  the  defect. 

As  with  the  rebuilding  of  the  contour  of  the  lips  so 
with  the  cheeks,  which  must  of  necessity  be  mobile  and 
flexible,  the  injection  of  hard  paraffin  is  out  of  the  ques- 
tion. The  author  has  observed  a  number  of  such  cases, 

23 


322     PLASTIC   AND   COSMETIC    SURGERY 

and  is  free  to  say  that  in  each  case  the  result  was  not 
only  abnormal  in  appearance,  but  a  source  of  great  an- 
noyance to  the  patient. 

What  is  worse  is  that  the  paraffin  once  injected  can 
never  be  removed  except  in  places  where  an  actual  en- 
cystment  has  taken  place,  in  which  case  the  hard  mass 
may  be  removed  through  a  small  incision  made  directly 
over  the  mass  and  introducing  a  grooved  director  into 
the  opening  then  by  the  rotation,  or  to-and-fro  move- 
ment of  which,  combined  with  digital  pressure,  the  cyst 
is  evacuated.  Once  the  mass  is  replaced  by  a  network 
of  connective  tissue  it  could  not  be  removed  except  by  an 
extensive  dissection  and  extirpation,  which  leaves  behind 
it  cicatrices  far  worse  than  the  appearance  of  the  parts 
before  operation. 

The  author  injects  cold  sterile  white  vaselin  below  the 
skin  here  and  there  about  the  cheek  at  the  sites  of  deep- 
est deficiency. 

These  injections  may  be  made  under  ethyl-chlorid  an- 
esthesia. 

Each  injection  is  carried  to  the  extent  of  causing  a 
lump  below  the  skin,  the  quantity  being  judged  from  a 
thorough  experience  with  similar  cases. 

After  the  injections  have  all  been  done,  the  thumb  of 
the  right  hand  is  passed  into  the  mouth  against  the  buccal 
mucous  membrane  of  the  left  cheek  and  the  index  finger 
over  it  externally  or  on  the  skin  surface.  For  the  right 
cheek  the  index  finger  instead  of  the  thumb  is  placed  in 
the  mouth.  The  mass  or  lumps  are  now  gently  pressed 
into  the  desired  shape  and  thickness  by  the  aid  of  these 
two  fingers.  A  few  drops  of  the  mass  may  be  forced  out 
of  the  needie  holes  under  this  procedure,  but  this  is  of  no 
consequence  when  it  is  considered  that  from  one  to  two 
ounces  may  have  been  injected  into  each  cheek. 

This  gliding  form  of  massage  should  be  continued 
until  the  entire  cheek  presents  an  even  and  rounded-out 
appearance. 


HYDROCARBON  PROTHESES      323 

It  will  l>e  found,  in  the  majority  of  cases,  that  the  in- 
tegument of  the  cheeks  about  the  region  of  the  inferior 
border  of  the  zygomatic  process  is  rather  firmly  adherent, 
and  that  a  subsequent  injection  will  be  necessary  to  ele- 
vate the  cheek  at  that  point. 

Injections  over  the  malar  bone  are  prone  to  cause  se- 
vere reaction,  leaving  a  puffed  appearance  just  below  the 
eyelids.  This  may  be  more  or  less  permanent  and  is  very 
undesirable.  It  should  be  avoided  by  injecting  very  small 
quantities  at  that  site.  It  is  always  safer  to  add  a  little 
subsequently. 

The  reaction,  generally,  is  not  severe,  and  is  readily 
controlled  by  cold  applications,  yet  the  author  has  experi- 
enced considerable  swelling  and  tenderness  in  two  cases 
of  total  cheek  deficiency  corrections  which  lasted  for  sev- 
eral weeks  after  the  operation,  giving  excellent  result 
eventually,  however.  Such  symptoms  are  dependent 
upon  circulatory  interference,  but  resolution  should  take 
place  without  untoward  results  with  judicious  treatment, 
unless  the  operator  has  been  negligent  by  injecting  one 
or  more  blood  vessels,  in  which  case  the  resultant  throm- 
bosis may  cause  breaking  down  of  the  subcutaneous  tis- 
sue, abscess,  evacuation  of  the  mass,  and  possibly  death 
in  part  of  the  integument.  The  precautions  referred  to 
in  avoiding  any  such  possibility  have  been  fully  given 
heretofore. 

Never  should  the  operator  hyperinject  the  cheeks, 
even  if  the  patient  insists  upon  looking  like  a  puffed  ball. 
He  should  be  satisfied  with  a  normal  contour,  and  truth- 
fully assure  the  patient  such  hyperinjected  contour  could 
not  be  retained  owing  to  the  weight  and  dropping  down 
of  the  mass  before  nature  could  properly  replace  it  by 
organized  tissue. 

Subsequent  injections  may  be  made  about  three  weeks 
after  the  first  sitting. 

With  nervous  and  hypercritical  patients  the  surgeon 
may  elect  to  give  the  patient  a  number  of  sittings,  inject- 


324     PLASTIC    AND    COSMETIC    SURGERY 

ing  only  small  quantities  at  two  or  three  places  each  time. 
This  in  the  majority  of  cases  will  give  better  results  than 
when  an  entire  cheek  is  injected,  for  the  reason  that  the 
larger  mass  is  likely  to  be  displaced  by  the  unconscious 
act  of  the  patient  in  sleeping  on  one  or  both  of  the  rebuilt 
cheeks  or  the  willful  massage  to  improve  the  handiwork 
of  the  surgeon  in  their  own  belief. 

Massage  of  the  cheeks  after  the  replacement  period  is 
not  to  be  tolerated.  It  tends  to  create  hyperplasia  by  cir- 
culatory stimulation. 

It  is  not  unusual  to  have  the  patient  tell  you  that  for 
weeks  after  the  replacement  period  the  cheeks  are  swollen 
considerably  in  the  morning  upon  arising,  going  down 
gradually  during  the  day. 

This  is  due  to  the  spongy  or  loose  character  of  the  new 
tissue  caused  to  be  formed  by  the  foreign  mass,  which 
gradually  takes  on  a  harder  and  more  compact  form. 

The  post-operative  dressing  will  be  either  adhesive 
isinglass  plaster  or  collodion.  With  the  former,,  moist 
applications  during  the  stage  of  reaction  are  not  permis- 
sible. 

DEFORMITIES  ABOUT  THE  ORBIT 

Deficiency  of  Lid  Contour  (Upper  and  Lower  Lids — Uni- 
lateral and  Bilateral). — The  lack  of  contour  in  the  eyelids 
is  not  as  frequently  met  with  as  redundancy  of  their  in- 
tegumentary structure;  there  are  cases,  however,  where 
the  eyes  seem  to  lie  deep  in  their  sockets,  owing  to  a  sink- 
ing in  or  a  collapse  of  the  surrounding  lids. 

This  condition  is  often  found  to  be  hereditary,  in 
other  cases  it  is  the  result  of  malnutrition,  a  peculiar  lack 
of  adipose  tissue  about  the  orbit  for  no  known  reason, 
or  fatty  degeneration  in  past  middle  life. 

The  fault  is  usually  bilateral.  In  rare  instances 
trauma  about  the  orbital  borders  may  result  in  lack  of 
nutrition.  Such  cases  are  usually  unilateral,  and  the 
upper  lid  is  affected  in  the  majority  of  cases. 


325 

The  correction  of  these  defects  is  found  to  be  rather 
difficult,  owing  to  the  thickness  of  the  tissue  under  consid- 
eration. 

The  use  of  hard  paraffin  plays  havoc  with  eyelid  tis- 
sue, rendering  it  hard,  immobile,  and  causing  a  hyper- 
plasia  of  the  new  connective  tissue  formed  thereby,  as 
well  as  the  peculiar  yellowish  pigmentary  spots  of  irregu- 
lar form  resembling  on  casual  inspection  xanthalasma. 
This  discoloration  has  been  fully  described  earlier  in  the 
work. 

The  author  has  had  occasion  to  remove  these  hard 
irregular  masses  investing  the  lower  lid  in  several  cases 
where  paraffin  had  been  injected,  also  two  cases  in  which 
the  pigmentary  discoloration  involved  both  upper  and 
lower  lids  associated  with  the  same  hard  fibrous  masses. 
Excision  under  local  anesthesia  and  silk  suture  was  the 
method  of  correction  employed. 

Prom  an  experience  of  twenty-two  cases  the  author 
believes  these  conditions  most  amenable  for  correction  by 
the  injection  of  sterile  oils  in  preference  to  any  other 
substance.  Even  white  vaselin  does  not  here  seem  to 
answer  the  purpose,  owing  to  its  stimulating  property  of 
causing  the  resultant  growth  of  connective  tissue. 

While  vaselin  injected  in  the  lids  causes  less  of  this 
new  tissue  to  be  formed,  such  tissue  is  never  of  the  con- 
sistency required.  This  is  especially  true  of  the  upper 
lids. 

The  oil  injected,  sterilized  sperm  oil  being  employed 
by  the  writer,  is  prone  to  absorption  of  more  or  less  de- 
gree, but  the  result  is  gratifying,  and  lasts  from  six 
months  to  one  year,  leaving  no  untoward  effect. 

If  the  absorption  has  been  sufficient  to  leave  the  parts 
as  before  the  operation,  a  subsequent  injection  of  the 
same  character  may  be  undertaken  six  months  from  the 
time  of  the  first  or  even  later,  as  the  patient  may  choose. 

The  tissue  of  the  eyelid  is  prone  to  swell  immediately 
the  oil  is  injected,  and  this  swelling  is  entirely  out  of 


326      PLASTIC    AND    COSMETIC    SURGERY 

proportion  to  the  quantity  introduced.  This  edema,  due 
to  a  retardation  by  pressure  of  the  blood  supply,  is  very 
misleading,  the  operator  believing  the  parts  overinjected. 
A  screw-drop  syringe  is  therefore  absolutely  required. 

A  fine  hypodermic  needle  is  used,  and  after  a  few 
drops  of  the  foreign  matter  have  been  injected,  the  lid 
should  be  massaged  gently  with  the  tip  of  the  indicis, 
employing  the  circular  movement. 

The  injection  should  be  made  at  the  outer  end  of  the 
lid  about  one  fourth  inch  above  or  below  the  canthus  for 
upper  or  lower  lid  respectively. 

The  needle,  slightly  dulled,  should  be  long  enough  to 
reach  the  full  length  of  the  part  to  be  injected.  Its  course 
can  be  readily  seen  under  the  thin,  overlying  skin. 

As  the  injection  progresses  slowly  and  evenly  the 
needle  is  withdrawn. 

A  second  puncture  or  injection  should  not  be  made  at 
one  sitting;  if  the  parts  are  underinjected  the  operation 
is  repeated  as  soon  as  the  swelling  of  the  lid  has  subsided, 
which  is  about  the  end  of  the  fourth  or  fifth  day. 

The  reaction,  apart  from  the  edema,  is  very  little, 
although  there  may  be  more  or  less  discoloration  of  the 
parts,  as  the  result  of  the  obstruction  offered  the  blood 
vessels. 

This  is  always  an  alarming  symptom  to  the  patient, 
but  passes  away  completely  in  the  usual  manner  in  sev- 
eral days. 

The  post-operative  dressings  may  be  collodion  or  silk 
protective. 

Cold  or  hot  applications,  as  may  be  best  borne  by  the 
patient,  can  be  used ;  they  tend  to  reduce  the  puffing  and 
lessen  the  ecchymosis.  The  patient  should  be  instructed 
to  lie  with  the  head  higher  than  usual  for  the  first  two 
nights  to  retard  the  edema. 

Furrow  about  Canthus  (Unilateral  and  Bilateral). — This 
condition  is  commonly  called  "  Crow's  Feet,"  and  is,  in 
the  majority  of  cases,  due  to  advancing  age,  but  is  ac- 


HYDROCARBON  PBOTHESES      327 

quired  by  habitually  contracting  the  eyelids,  as  in  laugh- 
ing or  grimacing.  It  is  particularly  noticeable  in  persons 
employed  in  the  drama. 

The  defect  is  usually  bilateral,  but  may  exist  at  one 
side  only  in  rare  cases. 

The  correction  is  easily  accomplished  by  this  method 
of  subcutaneous  injection,  although  a  reduction  of  the 
furrow  alone  does  not  suffice,  leaving  a  lump  or  elevation 
at  the  site.  The  author  shades  off  the  injection,  as  it 
were,  making  the  site  somewhat  conelike,  the  apex  being 
at  the  canthus  and  the  base  outward  toward  the  hair  line 
of  the  temporal  region. 

Sterile  oil  should  be  injected  near  the  canthus,  where 
the  overlying  integument  is  delicate.  One  such  injec- 
tion, covering  an  area  of  the  diameter  of  half  to  three 
fourths  of  an  inch,  should  be  made,  and  thus  backed  up 
or  built  outward  with  two  or  three  injections  of  the  white 
vaselin,  as  described  under  temporal  muscular  deficiency. 

The  hypodermic  needle  should  be  used  near  the  can- 
thus,  and  the  regular  one  over  or  about  the  temple. 

The  reaction  near  the  canthus  is  similar  to  that  with 
lid  injections.  The  same  post-operative  treatment  as 
with  the  lids  should  be  employed. 

Deficiency  of  the  Ocular  Stump. — It  frequently  happens 
that  by  reason  of  extensive  inflammatory  disease  and 
adjacent  adhesions  of  the  eye,  a  greater  part  of  the  globe 
must  be  excised  than  in  the  usual  case,  whether  the  oper- 
ation be  an  ordinary  excision,  the  Mules's  evisceration 
or  the  Frost  modification  of  the  latter. 

In  such  event  the  granular  button  or  the  stump  made 
of  Tenon's  capsule  is  too  small  to  permit  of  the  placing 
and  retention  of  the  artificial  eye.  In  other  instances  the 
stump  is  so  contracted  that  while  the  artificial  eye  is 
retained  it  must  of  necessity  be  allowed  to  rest  deep  in 
the  socket,  destroying  the  entire  contour  of  the  orbit. 
Again  in  the  enucleation  operation  so  little  of  Tenon's 
capsule  engages  the  artificial  eye  that  movement  is  en- 


328     PLASTIC    AND    COSMETIC    SUKGKEY 

tirely  destroyed,  particularly  when  the  Mules's  glass 
globe  has  not  been  introduced. 

Excellent  results  may  be  obtained  in  some  of  these 
cases,  others  are  not  amenable  to  the  injection  method 
because  of  a  lack  of  sufficient  stump  to  inject,  and  the 
danger  of  injecting  through  the  posterior  wall  of  the  cap- 
sule, the  mass  in  part  escaping  into  the  orbital  apex, 
where  it  is  liable  to  impinge  sufficiently  upon  the  remains 
of  the  optic  nerve  to  cause  sympathetic  inflammation  of 
the  normal  eye.  A  condition  at  once  not  easily  corrected, 
proving  dangerous  to  the  sight  of  the  healthy  eye,  and 
possibly  producing  a  fatal  termination. 

It  is  with  the  use  of  paraffin,  liquefied  by  heat  and  in- 
jected in  this  state,  that  such  fatal  cases  as  have  been 
placed  on  record  have  been  operated.  The  liquid  mass 
under  pressure  forced  into  a  soft  pultaceous  mass  cannot 
be  easily  controlled,  if  at  all,  and  accidents  here  are  of 
more  serious  import  than  in  any  other  part  of  the 
human  anatomy,  apart  from  the  direct  injection  of  a 
facial  artery  of  sufficient  size  to  produce  an  alarming  em- 
bolism and  death. 

The  author  cannot  speak  too  forcibly  against  such 
irrational  procedure.  Other  surgeons  are  beginning  to 
realize  the  danger  of  the  use  of  hard  paraffin  injections 
near  the  eye. 

The  proper  and  safe  method  of  improving  the  stump 
is  to  introduce  into  it,  under  local  eucain  or  cocain  anes- 
thesia, small  masses  of  the  mixture  of  vaselin  and  paraf- 
fin in  cold  state.  These  injections  into  the  stump  and 
mucous  membra'ne  should  be  done  several  weeks  apart, 
always  keeping  a  respectful  distance  from  the  remains 
of  the  optic  nerve. 

The  injections  should  be  begun  as  near  to  the  surface 
as  possible  without  breaking  down  the  tissue  by  necrosis, 
keping  in  mind  that  one  or  two  of  such  successfully  intro- 
duced masses  will  do  much  toward  supporting  the  arti- 
ficial eye. 


HYDROCARBON   PKOTIIESES  329 

If  necessary  the  mucous  membrane  back  of  the  pal- 
pebral  rim  can  be  injected  in  like  manner  to  give  firmer 
hold  to  the  eye  and  at  the  same  time  give  support  to  the 
usually  depressed  and  atrophied  lids. 

Wet  dressings  are  applied  to  allay  the  reactive  in- 
flammation, which  should  be  proportionate  in  severity  to 
the  amount  of  the  mass  injected. 

In  three  cases  operated  upon  by  the  author  excellent 
results  were  attained,  and  no  untoward  results  had  been 
experienced  two  years  after  injection. 

DEFORMITIES  ABOUT  THE  CHIN 

Anterior  and  Lateral  Deficiencies. — An  anterior  lack  of  con- 
tour of  the  chin  is  generally  regarded  as  of  the  receding 
type.  With  this  is  usually  found  a  bilateral  lack  of  form, 
especially  in  men.  With  a  generally  well-formed  face 
such  a  chin  gives  it  a  weak  and  ofttimes  a  degenerate 
appearance.  In  women  a  deficient  chin  is  not  as  notice- 
able, because  of  the  smallness  of  the  face  in  general  and 
the  predomination  of  the  oval  type. 

The  lack  of  prominence  about  the  chin  may  be  ante- 
rior only,  the  broadness  being  sufficient,  due  to  a  lack 
of  development  of  the  mental  process,  or  it  may  be  defi- 
cient laterally  with  a  pronounced  mental  prominence, 
giving  it  a  sharp,  protruding,  or  pointed  appearance,  or 
the  lack  of  form  is  combined,  as  is  commonly  the  case. 

Such  chins  may  be  made  to  appear  normal,  and  even 
ideal,  by  the  subcutaneous  injection  method.  The  type 
of  chin  most  favored  by  American  men  is  the  square 
angular,  now  so  plentifully  seen  in  pen-and-ink  illustra- 
tions. 

The  tissue  of  the  chin  lends  itself  readily  to  the 
building-up  process.  Almost  any  form  may  be  attained 
by  the  judicious  employment  of  the  method  under  con- 
sideration. 

While  it  is  true  excellent  results  may  be  obtained  with 
hard  paraffin,  used  in  liquefied  form,  it  can  often  be 


330 


HYDROCARBON  PBOTHESES      331 

shown,  however,  that  the  paraffin  injected  under  pres- 
sure will  run  down  in  narrow,  pencil-like  streams  under- 
neath the  chin  and  skin  of  the  anterior  aspect  of  the 
neck,  where  they  may  be  felt  afterward  as  hard  oval 
cysts  or  of  elongated  form.  This  is  not  possible  when 
the  cold  mixture  of  vaselin  and  paraffin  is  used,  since  the 
position  of  the  mass  can  be  easily  followed  with  the  eye 
or  felt  with  the  fingers. 

The  injections  should  be  made  from  either  angle  at 
the  first  sitting.  Enough  of  the  mass  should  be  intro- 
duced to  leave  a  ridgelike  formation  across  the  anterior 
chin,  varying  in  thickness  according  to  the  shape  of  the 
chin  previous  to  operation  and  the  form  desired. 

It  is  not  well  in  chins  of  very  deficient  type  to  at- 
tempt to  make  the  anterior  contour  as  it  should  be  in  the 
first  sitting.  Too  much  pressure  would  be  required,  and 
unless  the  skin  was  freely  movable  considerable  reactive 
inflammation  would  result,  with  possible  necrosis  of  the 
skin  in  part  and  consequent  expulsion  of  the  injected 
mass. 

The  anterior  line  of  such  chins  should  be  rebuilt  in 
several  sittings,  always  waiting  for  the  parts  to  become 
normal  in  appearance  and  sensitiveness. 

This  method  helps  to  stretch  the  skin,  allowing  of 
further  injections  and  the  introductions  of  a  greater 
quantity  than  could  be  introduced  at  one  time  only. 

The  author  advocates  making  two  or  three  sittings 
of  the  anterior  restoration  of  contour  and  two  for  each 
angle. 

The  angles  of  the  chin  are  injected  at  a  point  about 
midway  between  the  mental  process  and  beginning  of 
external  oblique  line.  The  mass  is  injected  as  near  the 
inferior  ridge  as  possible,  and  somewhat  above  the  at- 
tachment of  the  platysma  myoides  muscle. 

Only  one  needle  insertion  is  made  at  each  angle,  and 
the  mass  is  injected  until  a  round  elevated  tumor  is  at- 
tained, which  is  pinched  or  squeezed  with  the  fingers 


332 


HYDROCARBON  PROTHESES      333 

into  the  desired  angular  form,  one  finger  being  placed 
over  the  needle  opening  to  avoid  squeezing  the  mass 
out. 

It  can  be  readily  seen  that  with  this  puttylike  mass 
much  better  results  than  with  the  comparatively  soft 
vaselin  could  be  obtained  while  with  the  liquefied  paraf- 
fin the  operator  would  be  at  a  loss  to  know  just  what 
had  been  accomplished  until  the  mass  had  become  fairly 
solidified,  and  then  often  finding  the  semisolid  mass, 
which  required  rapid  molding  to  give  the  desired  shape 
before  it  would  become  hard  and  unmanageable,  in  a  dif- 
ferent position  and  much  more  distributed  than  he  had 
expected. 

For  the  latter  reason  repeated  small  injections  have 
been  advised,  but  the  author  believes  oft-repeated  injec- 
tions of  paraffin  in  a  small  area  are  prone  to  set  up  con- 
siderable disturbance,  and  that  the  resultant  tissue  re- 
placement is  interfered  with.  Furthermore,  the  injected 
mass  would  eventually  be  in  grape-bunch  like  form,  and 
in  that  condition  not  as  manageable  or  inducive  to  the 
establishment  of  contour  angulation,  such  as  is  required 
in  the  chin.  The  final  appearance  of  chins  thus  rebuilt 
is  heavy  and  rounded,  lacking  the  concavity  above  the 
inferior  prominence  along  the  anterior  line  as  well  as 
the  angulation  laterally. 

With  the  cold  mixture  advised  a  considerable  mass 
may  be  injected  at  one  sitting,  which  is  easily  molded 
into  form  and  which  retains  that  form  unless  the  reac- 
tive inflammation  is  severe.  This  should  not  follow  un- 
less actual  hyperinjection  has  been  done  or  an  unclean 
product  has  set  up  an  infective  cellulitis. 

When  the  chin  is  uncommonly  peaked,  or  small,  it 
may  be  found  necessary  to  inject  both  sides  of  the  chin 
beyond  the  angle  and  in  an  upward  direction  slightly 
below  and  following  the  external  oblique  line. 

Such  deficiency  may  be  found  decidedly  unilateral  as 
a  result  of  lack  of  development  of  one  half  of  the  lower 


334      PLASTIC    AND    COSMETIC    SURGERY 

maxillnry  hone,  a  resection  of  either  maxilla  for  what- 
ever cause,  imperfect  union  following  fracture  or  dis- 
ease of  the  bone  early  in  life. 

In  such  cases  the  lateral  deficiency  must  be  first  re- 
stored, using  the  same  method,  before  the  chin  proper 
can  be  built  up.  Ofttimes  the  lower  cheek  of  the  affected 
side  must  also  be  injected.  This  should  be  done  after 
the  site  overlying  the  former  body  of  the  maxilla  of  the 
affected  side  has  been  rebuilt.  The  cheek  should  then 
be  built  out  above  this  hard  linear  mass  by  the  injection 
of  cold  white  vaselin,  as  heretofore  referred  to. 

The  following  illustrations  show  a  chin  deficient  an- 
teriorly and  laterally  before  and  the  result  after  correc- 
tion. 

The  post-operative  treatment  should  be  collodion 
dressing,  followed  by  cold  antiseptic  applications  for  at 
least  two  days.  The  latter  ameliorates  the  inflammation 
and  helps  to  retain  the  molded  shape  of  the  mass.  Sub- 
sequent sittings  may  be  made  one  a  week  or  ten  days 
apart. 

DEFORMITIES  ABOUT  THE  EAR 

Pro-auricular  Deficiency  (Unilateral  and  Bilateral). — A 
deep  furrow  in  front  of  the  ear  may  be  found  unilateral 
in  hemiatrophy  of  the  face,  but  the  condition  is  usually 
a  bilateral  one,  due  to  malnutrition  or  the  fatty  degen- 
eration of  past  middle  age.  In  the  latter  case  the  de- 
pression is  accompanied  by  a  redundancy  and  wrinkling 
of  the  skin. 

Owing  to  the  close  proximity  of  the  large  temporal 
vessels  a  hard  mass  should  never  be  injected  subcutane- 
ously  for  the  relief  of  this  condition.  Even  the  mixture 
of  vaselin  and  paraffin  has  caused  considerable  reaction 
when  injected  to  overlie  these  vessels. 

The  author  advises  the  injection  of  white  sterile  vase- 
lin or  sperm  oil  for  this  form  of  correction.  It  should 
be  carefully  injected,  since  the  vessels  lie  close  to  the 


HYDROCARBON  PEOTHESES      335 

skin  with  the  anterior  auricular  crossing  transversely 
about  the  center  of  the  furrow. 

Every  precaution  should  be  taken,  one  injection  only 
being  made  from  below  upward  at  each  sitting  if  more 
than  one  is  necessary,  and  then  only  after  the  needle 
has  been  unscrewed  from  the  syringe  to  make  sure  vessel 
bleeding  does  not  follow  the  puncture. 

The  reaction  is  usually  severe,  with  considerable 
edema  and  ecchymosis. 

The  resultant  tissue  formation  likewise  is  active,  and 
hyperplasia  at  this  site  is  not  uncommon,  especially  if 
the  mixture  or  hard  paraffin  has  been  employed. 

A  cellulitis  following  such  an  injection  is  exceedingly 
troublesome,  the  injected  mass  being  thrown  off  usually 
at  the  base  of  the  furrow,  which  is  followed  by  a  low 
type  of  inflammation  with  a  protracted  oozing  of  serous 
exudate.  Should  such  a  case  come  under  the  care  of  the 
surgeon,  thorough  cleansing  of  the  affected  site  under 
scrupulous  antisepsis  should  be  done  at  once,  and  wet 
antiseptic  dressings  be  applied  daily  until  the  wound  is 
entirely  healed. 

A  plastic  skin  operation  must  be  done  in  most  of  these 
cases  to  overcome  the  ragged  cicatrix  formed  upon  heal- 
ing of  the  wound.  This  should  never  be  undertaken  until 
the  wound  has  been  healed  for  several  weeks  at  least. 

After  the  injection  of  the  parts  cold  antiseptic  dress- 
ings should  be  applied  at  once,  and  kept  up  until  every 
sign  of  reactive  inflammation  has  subsided.  At  no  time 
should  the  subsequent  injection  be  undertaken  before  a 
month  has  elapsed  from  the  time  of  the  former  operation. 

Post-auricular  Deficiency. — This  defect  is  invariably  uni- 
lateral, and  then  the  result  of  a  mastoid  operation. 

The  skin  about  the  depressed  site  will  be  found  to  be 
more  or  less  firmly  adherent,  necessitating  subcutaneous 
dissection  before  an  injection  for  correction  can  be  under- 
taken. 

In  this  case  the  cold  mixture  of  vaselin  and  paraffin 


is  indicated,  since  the  softer  products  will  hardly  suffice 
to  elevate  the  tense  skin.  If  the  former,  surgical  opera- 
tion has  been  done  some  time  previous  to  the  required 
injection  the  parts  may  at  one  or  two  sittings  be  restored 
to  a  fairly  normal  contour,  depending  entirely  upon  the 
amount  of  ungiving  scar  tissue  at  the  site.  If  the  parts  are 
tender  and  not  reduced  to  normal,  the  injections  should 
be  made  frequently,  about  ten  days  apart,  injecting  a 
small  mass  across  and  through  the  subcutaneous  scar 
attachment  at  each  sitting. 

The  reactions  following  such  injections  help  to  tease 
the  scar  away  from  the  bony  tissue,  but  should  not  be 
sufficient  to  cause  extensive  inflammation. 

The  same  mode  of  post-operative  treatment  as  has 
been  given  with  pro-auricular  corrections  should  be  fol- 
lowed. 

SPECIFIC   TECHNIQUE   FOR  THE   CORRECTION   OF 
DEFORMITIES   ABOUT  THE  SHOULDERS 

Deficiencies  about  the  base  of  the  neck  and  ,the  shoul- 
ders are  very  commonly  found  in  women.  These  defects 
are  usually  bilateral,  except  in  rare  cases.  The  much-de- 
sired contour  is  readily  restored  by  the  subcutaneous-in- 
jection method,  and  since  the  technic  for  one  part  is  the 
same  as  for  the  whole  there  is  no  need  to  dilate  specific- 
ally upon  the  treatment  of  each  part. 

The  author  advocates  the  injection  of  cold  sterile 
white  vaselin  only,  for  the  restoration  of  the  contour 
about  the  neck,  anterior  and  posterior  shoulder,  and  the 
mammas,  except  in  the  unilateral  correction  of  a  flattening 
of  the  breast  following  amputation  for  the  removal  of 
neoplasms,  when  the  mixture  of  white  vaselin  and  paraf- 
fin should  be  used,  owing  to  the  tenseness  of  the  skin  fol- 
lowing the  excision  of  a  large  part  of  the  integument  cov- 
ering the  diseased  gland. 

In  the  restoration  of  the  contour  about  the  neck  and 
shoulders  it  is  well  for  the  surgeon  to  familiarize  himself 


HYDROCARBON  PROTHESES      337 

thoroughly  with  the  superficial  veins  of  the  parts,  since 
the  vessels  here  are  larger,  and  the  introduction  of  for- 
eign matter  into  them  is  liable  to  lead  to  serious  and  even 
fatal  results. 

The  injections  should  never  be  made  until  the  oper- 
ator has  assured  himself  of  the  fact  that  a  vessel  has  not 
been  entered  into,  and  then  only  should  a  small  quantity 
of  the  mass — i.  e.,  about  two  or  three  drams — be  injected 
at  one  point. 

The  easiest  mode  of  introducing  the  needle  is  to  pinch 
up  the  skin  between  the  fingers  of  one  hand,  introducing 
the  needle  into  the  fold  thus  raised.  As  the  mass  is  in- 
jected the  skin  should  be  raised  by  aid  of  the  needle, 
so  as  to  allow  all  the  immediate  room  possible  for  its 
reception. 

The  mass  injected  is  at  once  molded  down  flat  with 
the  thumb  or  forefinger. 

A  number  of  such  injections  may  be  made  at  both 
sides  at  the  one  sitting.  The  ethyl-chlorid  spray  may  be 
employed  to  render  the  parts  less  painful.  At  no  time 
should  the  entire  shoulders  be  filled  at  one  sitting,  for 
fear  that  the  reaction  may  be  severe  or  that  for  any  un- 
foreseen cause  infection  results  which  would  in  such  in- 
stance be  indeed  difficult  of  treatment,  eventually  leaving 
the  parts  scarred  and  unsightly. 

Nor  should  the  mass  be  injected  intracutaneously,  a 
fault  sometimes  observed  about  the  base  line  of  the  neck 
anteriorly  and  laterally  where  the  operator  has  been 
timid  in  avoiding  the  exterior  and  anterior  jugular  veins. 
Such  injections  invariably  result  in  abscess,  or  when  not 
extensive  enough  to  cause  necrosis  the  skin  assumes  a 
more  or  less  permanent  red  or  yellow  discoloration  over 
the  site  so  injected. 

The  treatment  for  the  partial  or  total  removal  of  such 
spots  has  been  referred  to. 

In  the  average  case  of  contour  restoration  of  the 
shoulders  about  eight  sittings  are  required,  two  sittings 

23 


338     PLASTIC    AND    COSMETIC    SURGERY 

being  given  each  week,  and  as  many  injections  made  as  is 
deemed  necessary  or  advisable  at  each. 

All  the  precautions  of  technic  heretofore  given 
should  be  employed.  The  reaction  following  such  injec- 
tions is  never  severe,  and  little  or  no  treatment  is  neces- 
sary. 

The  needle  openings  are  covered  with  aristol  collodion 
or  the  isinglass  adhesive  plaster. 

At  the  end  of  six  months  or  more  after  the  injected 
matter  has  been  quite  thoroughly  replaced  with  new  con- 
nective tissue  it  is  often  found  necessary  to  inject  small 
quantities  here  and  there  about  the  shoulders,  owing  to 
the  contraction  of  the  new  tissue  and  its  ultimate  fixed 
disposition  about  the  parts  more  than  to  the  absorption 
of  the  mass  injected. 

Furthermore,  a  certain  amount  of  edema  or  swelling 
follows  the  injection  of  any  foreign  matter  under  the 
skin  which  is  not,  in  cases  of  this  kind,  so  readily  absorbed, 
giving  during  that  period  of  time  a  more  pronounced 
contour  or  fullness,  which,  passing  away  in  the  natural 
course  of  events,  does  not  imply  the  absorption  of  the 
matter  injected — a  statement  so  often  made  by  those  not 
in  favor  of  using  paraffins  of  low  melting  points  for  sub- 
cutaneous protheses. 

Such  result,  however  extensive,  as  it  might  be  in  some 
cases  for  the  lack  of  proper  injection  or  in  the  case  with 
oil  injections  is  at  all  times  correctable,  while  the  hyper- 
plastic  knobs,  so  often  following  the  injection  of  paraf- 
fins of  high  melting  points  about  the  shoulder,  can  only 
be  removed  by  surgical  means,  which  leave  the  parts  more 
unsightly  than  before  anything  had  been  done  for  the 
patient. 


CHAPTER   XV 

EHINOPLASTY 
(Surgery  of  the  Nose) 

EHINOPLASTIC  operations  serve  to  correct  deformities 
of  or  restore  the  nose.  Such  operations  may  involve  only 
a  part  of  or  the  entire  organ,  hence  may  be  termed  par- 
tial or  total.  Furthermore,  a  fine  distinction  may  be 
drawn  between  general  rhinoplasty  as  applied  to  such 
deformities  when  caused  by  traumatism,  the  excision  of 
neoplasms  or  destructive  disease,  whether  such  correc- 
tion be  partial  or  total,  and  cosmetic  rhinoplasty  when 
such  corrections  are  made  purely  with  the  object  of  im- 
proving the  nasal  form  when  the  deformity  is  either 
hereditary  or  the  result  of  remote  accident. 

For  some  unaccountable  reason  the  latter  art  has  not 
met  with  the  general  favor  the  profession  should  grant 
it,  yet  the  results  obtained  by  such  specialists  as  have 
undertaken  this  artistic  branch  of  surgery  have  been  all 
that  could  be  desired,  and  have  consequently  added  much 
to  the  comfort  and  happiness  of  the  patient. 

Without  a  comparatively  thorough  knowledge  of  the 
extent  of  cosmetic  rhinoplasty  it  would  be  difficult  to 
draw  any  conclusion  as  to  the  value  of  this  art.  If  it  has 
not  met  with  the  favor  it  deserves  it  is  solely  due  to  the 
fact  that  the  art  has  been  limited  to  the  few,  and  the  lit- 
erature on  the  subject  is  so  meager,  indeed,  that  the  sur- 
geon has  been  compelled  in  many  cases  to  trust  to  his 
own  originality  in  undertaking  an  operation  of  this 
nature. 

339 


The  limitation  to  rhinoplasty  is  due  primarily  to  the 
artistic  skill  required  to  obtain  results;  secondly,  to  the 
risks  involved  by  loss  of  tissue  due  to  gangrene,  imper- 
fect healing  or  accidental  interference,  post-operatio ; 
and  thirdly,  to  scarring  about  the  face  as  a  result  of 
the  primary  and  secondary  wounds;  in  fact,  so  much 
so  that  many  surgeons  prefer  to  allow  a  small  defect 
to  remain,  to  escape  the  risks  involved  in  correcting 
them. 

The  author  believes  such  fear  misplaced,  because  with 
the  methods  of  surgery  of  the  present  day  and  the  proper 
knowledge  of  the  art  there  need  be  little  risk  involved 
and  the  result  expected  should  be  as  near  perfect  as 
human  skill  can  make  it. 

True,  a  surgeon  cannot  be  expected  to  build  an  entire 
nose  from  the  skin  or  other  tissue  of  the  forehead  or 
cheeks  and  make  it  a  thing  of  aforethought  beauty  and 
shape,  but  if  the  result  be  no  more  than  a  curtain  of  skin 
to  hide  the  hideous  deformity  he  has  done  his  share,  and 
such  result  is  the  worst  he  might  look  forward  to. 

For  the  correction  of  nasal  deformities  the  author 
will  consider  first  such  operations  as  involve  the  entire 
loss  of  the  nasal  organ  or  total  rhinoplasty;  thereafter 
partial  loss  of  the  nose,  and  lastly  such  cases  involving  no 
loss  of  tissue  and  dependent  on  malformation  only  under 
cosmetic  rhinoplasty. 

It  is  not  here  intended  to  lay  down  a  law  for  the  sur- 
geon for  the  restoration  of  the  entire  or  part  of  the  nose 
for  the  reason  that  each  case  differs  more  or  less ;  that  in 
each  case  there  is  more  or  less  tissue  that  may  be  utilized, 
and  that  there  are  many  methods  advanced  for  such  pro- 
cedure, but  the  author  does  desire  to  give  to  the  operator 
a  concise  and  comprehensive  treatise  on  rhinoplasty  and 
to  illustrate  the  best  of  such  operations  as  have  been 
placed  on  record  as  a  ready  guide  and  for  immediate 
reference — a  matter  of  no  small  moment  when  this  lit- 
erature can  be  gained  only  by  searching  through  innumer- 


BHINOPLASTY  341 

able  medical  journals  and  short  references  and  in  all 
languages  of  the  civilized  world. 

In  the  chapter  on  history  some  idea  of  the  time  in 
which  rhinoplasty  has  been  practiced  may  be  obtained. 
It  is  not  deemed  necessary  to  go  into  further  historical 
facts  here,  except,  perhaps,  to  divide  the  subject  into  the 
three  most  important  schools  or  countries  that  have 
given  individuality  to  the  art. 

THE  CAUSES  OF  NASAL  DESTRUCTION 

The  loss  of  the  entire  nose  may  be  due  to  traumatism, 
actual  amputation,  the  bites  of  man  or  beast,  duels,  the 
removal  of  neoplasms,  gangrene  after  freezing  or  disease, 
rhinosclerosis,  syphilis,  the  application  of  caustics,  tuber- 
cular disease,  lupus,  cancer,  and  rarely  congenital  absence 
of  the  organ.  The  loss  may  be  total  or  partial. 

The  extent  of  loss  of  substance  in  each  case  differs, 
and  it  is  for  this  reason  that  surgeons  have  been  com- 
pelled to  originate  many  methods  of  operation,  each  hav- 
ing for  its  object  to  correct  the  deformity  as  neatly  and 
as  near  to  the  normal  as  possible. 

CLASSIFICATION  OF  DEFORMITIES 

To  give  correctly  a  classification  of  nasal  deformities 
would  simply  mean  to  mention  each  anatomical  part  or 
division  of  the  nose  referring  to  the  deformity  involving 
the  same.  For  this  reason  such  an  arrangement  would 
be  uselessly  extensive,  but  for  the  proper  recording  of 
such  cases  the  author  advises  a  systematic  method  of 
nomenclature  in  which  the  deformity  is  stated,  as:  left, 
unilateral  deficiency  of  inferior  lobule;  or  right,  median 
third  deficiency  of  nasal  dorsum  of  the  parts  destroyed 
and  mentioned  as  such. 

A  fair  idea  of  typical  deformities  may  be  obtained 
from  the  following  illustrations  in  which  deformities 
from  the  milder  to  the  most  extensive  extent  are  shown ; 


342      PLASTIC    AND    COSMETIC    SUEGEKY 

The  types  here  shown  are  all  pathological  with  the 
exception  of  Fig.  306,  in  which  a  saddle  nose  is  illustrated 


FIG.  306. — DEFICIENCY   OF   SUPERIOR      FIG.  307. — POST-ULCERATIVE  DEFORM- 
AND    MIDDLE     THIRD     OF     NOSE.          ITY  OF  SUPERIOR  THIRD  OF  NOSE. 
(Saddle  Nose.) 


FIG.  308. — Loss   OF  RIGHT  ALA,  LOB- 
ULE AND  COLUMNA. 


FIG.  309. — Loss  OF  LOBULE,  INFERIOR 
SEPTUM  AND  COLUMNA. 


BHINOPLASTY 


343 


which  may  or  may  not  be  the  result  of  disease  or  trauma- 
tism. 


FIG.  310. — ULCERATIVE  Loss  OP  RIGHT      FIG.  311. — Loss  OF  NASAL  BONES  AND 
MEDIAN   LATERAL    SKIN   OF    NOSE  PARTIAL  ULCERATIVE  DESTRUCTION 

WITH  INVOLVEMENT  OF  ALA.  OF  DORSUM,  LOBULE  AND  SEPTUM 

OF  NOSE. 


FIG.    312.  —  DESTRUCTION    OF    NASAL          FIG.  313. — TOTAL  Loss  OF  NOSE. 
BONES  WITH  DORSAL  INTEGUMENT 
AND  LOBULE  INTACT, 


344      PLASTIC    AND    COSMETIC    SUKGERY 

Many  other  deformities  of  the  nose  exist,  of  course, 
such  as  lateral  deviation,  twists,  etc.,  but  as  in  most  of 
such  cases  cosmetic  rhinoplastic  operations  and  subcu- 
taneous injection  are  required  for  their  correction,  inas- 
much as  in  these  cases  the  skin  is  healthy  and  intact,  they 
will  be  considered  under  that  part  of  the  chapter  that  has 
to  do  with  purely  cosmetic  rhinoplasty  or  under  the 
chapter  on  subcutaneous  protheses. 


SURGICAL  TECHNIQUE 

Before  going  into  the  individual  methods  involved  in 
the  correction  of  deformities  of  the  nose,  it  is  well  here 
to  go  into  the  special  details  required  for  the  perform- 
ance of  operations  about  the  nose  proper. 

Anesthesia. — It  may  be  well  here  to  state  that  many  of 
the  smaller  or  cosmetic  operations  can  and  should  be  done 
under  local  anesthesia,  and  that  the  anterior  nares  should 
be  plugged  to  prevent  the  blood  from  running  into  the 
pharynx,  but  in  operations  of  greater  extent  the  poste- 
rior nares  should  be  pluggged  by  Bellocq  or  other  meth- 
od, and  that  since  the  patient  must  be  placed  under  a 
general  anesthetic,  some  special  plan  must  be  followed  to 
give  the  same. 

The  author  has  found  no  special  apparatus  on  the 
market  for  this  purpose.  A  most  practical  apparatus 
may  be  made  as  follows :  A  medium  hard  piece  of  rubber 
is  cut  into  such  shape  as  will  fit  into  the  patient's  mouth 
between  the  lips  and  the  teeth.  In  its  center  a  hole  is 
made,  into  which  a  metal  tube  is  fixed  to  which  a  rubber 
tube  of  three-fourth-inch  diameter  is  securely  fastened. 
This  tube  is  connected  by  its  distal  end  to  the  anesthetic 
container,  which  should  be  so  constructed  as  to  permit 
the  required  amount  of  air  to  be  given  with  the  anesthetic 
at  the  desired  time. 

Such  an  apparatus  practically  seals  the  oral  orifice, 
and  prevents  blood  from  flowing  into  the  mouth,  gives 


EHINOPLASTY  345 

the  operator  a  free  field  to  work  in  without  the  encum- 
brance of  large  external  mouthpieces,  and  is  one  that 
in  case  of  vomiting  can  be  easily  removed  for  the  time 
being,  and  be  replaced  without  interference  to  the  sur- 
geon. 

Preparation  and  Cutting  of  Nasal  Flaps. — Under  a  division 
of  skin  grafting  some  preliminary  steps  in  the  prepara- 
tion and  cutting  of  a  nasal  flap  has  been  referred  to,  but 
the  author  thinks  it  timely  to  repeat  here  the  necessity 
for  a  systematic  method  of  procedure. 

It  is  well  for  the  surgeon  to  have  fully  decided  upon 
the  certain  operative  plan  he  is  to  follow  several  days 
prior  to  the  operation.  He  must,  especially  in  total  rhino- 
plastic  cases,  prepare  a  paper  or  oiled  silk  model  of  the 
flap  or  flaps  he  has  decided  upon  to  take  from  the  fore- 
head or  cheek,  and  to  fold  and  bend  this  model  into  the 
place  of  the  deformity  to  be  overcome,  to  make  sure  of 
the  result  to  be  attained,  allowing  for  the  loss,  if  any,  of 
mass  by  reason  of  the  torsion  of  the  flap  at  its  pedicle. 

If  the  hair  of  the  frontal  scalp  lies  within  the  flap  out- 
line, it  should  be  shaven  away  well  beyond  the  border 
to  permit  of  unhindered  work. 

Thoroughly  cleanse  and  keep  clean  with  a  suitable 
antiseptic  the  parts  to  be  operated  upon  for  at  least 
twenty-four  hours. 

Place  a  rubber  cap  over  the  hair  of  the  head,  or  a  fixed 
gauze  or  waterproof  arrangement  to  keep  it  in  place. 

If  there  be  any  hair  adornment  of  the  face  remove  it. 

The  surgeon  should  remember  to  get  the  flaps  to  be 
utilized  on  forming  the  lost  parts  of  the  nose,  at  least  one 
third  larger  to  overcome  the  consequent  retraction. 

Sterilized  sutures,  preferably  silk  of  suitable  size, 
should  be  ready  and  be  cut  of  such  length  as  will  facilitate 
quick  action. 

Rubber  tubes  of  proper  diameter  for  insertion  into  the 
nares  should  be  at  hand  if  required. 

When  all  is  ready  the  operator  is  to  proceed  quickly 


346      PLASTIC    AND    COSMETIC    SURGERY 

and  accurately,  never  changing  his  prearranged  idea  of 
the  operation.  His  assistants  should  be  ready  to  control 
by  torsion  or  pressure  the  bleeding  occasioned  by  cut- 
ting, since  it  covers  the  field  of  operation  and  hinders 
rapid  work. 

The  surgeon  in  making  flaps  should  use  the  greatest 
gentleness  in  handling  them  to  prevent  pressure  gan- 
grene. His  finger  tips  are  far  better  than  fixation  for- 
ceps. Sharp  tenaculi  may  be  employed  with  gentle  trac- 
tion only.  Never  permit  the  use  of  serrated  forceps  in 
autoplasty. 

In  cutting,  employ  the  rules  laid  down  under  the  prin- 
ciples of  plastic  surgery,  and  in  dressing  flap  operations 
such  methods  as  have  been  heretofore  described. 

Dressing. — Do  not  be  too  hasty  in  dressing  such  wounds, 
as  early  interference  often  results  in  partial  if  not  total 
loss  of  the  flap. 

The  author  has  found  that  in  flap  operations  blood 
dressing  under  perforated  rubber  tissue  is  best.  This 
helps  to  give  nutriment  to  the  parts  and  permits  of  free 
removal  of  the  dressings.  Never  apply  the  blood  treat- 
ment on  gauze,  since  the  latter  is  liable  to  become  hard 
and  attached  to  the  suture  lines,  requiring  undue  force 
for  its  removal. 

Care  of  the  Nares. — Remove  all  packing  from  the  nares 
before  fixing  the  lobular  section  of  the  flap,  and  have  all 
bleeding  controlled  before  suturing  the  part  of  the  flap 
intended  for  the  columna.  Blood  clots  tend  to  pressure 
and  infection.  If  nare  tubes  are  used  rather  let  them 
remain  in  place  for  some  time  than  to  drag  them  forth 
forcibly. 

The  interior  nose  and  nares  can  be  kept  clean  by  gen- 
tle irrigation  through  them. 

Number  of  Operations. — Instruct  the  patient  as  to  the 
probable  outcome  of  the  operation,  and  advise  him  that 
more  than  two  or  three  operations  may  be  necessary  to 
correct  the  deformity. 


RHINOPLASTY  347 

Von  Esmarch  has  said  that  twenty  operations  about 
the  nose  are  none  too  many  if  the  desired  result  can.be 
obtained.  Dieffenbach  has  said  that  it  is  more  difficult 
to  restore  smaller  nasal  defects  than  those  of  greater 
extent. 

The  latter  applies  particularly  to  cosmetic  operations 
in  which  the  surgeon  is  compelled  to  work  through  small 
openings  or  incisions  always  with  the  view  of  leaving 
little  if  any  scar,  and  to  place  such  scar  where  it  may  be 
least  observed. 

The  best  cosmetic  surgeon  is  he  who  can  accomplish 
results  with  the  least  secondary  disfigurement. 

PROTHESES 

When  for  any  cause  there  is  a  loss  of  the  entire  nose, 
and  the  patient  is  unwilling  to  undergo  surgical  opera- 
tion for  its  restoration,  the  surgeon  may  resort  to  the 
use  of  protheses  or  artificial  noses. 

Such  noses  are  made  of  papier-mache,  rubber,  wood, 
or  light  metal,  and  painted  to  imitate  the  color  of  the  skin 
of  the  individual.  They  should  be  made  after  a  model 
previously  prepared  by  molding  the  new  organ  upon  the 
face  of  the  patient  or  after  such  patterns  as  the  surgeons 
may  have  to  choose  from,  fitting  the  skin  juncture  accu- 
rately in  such  cases. 

If  the  surgeon  lacks  such  artistic  ability,  a  sculptor 
should  be  employed  to  model  the  proper  organ  suitable 
for  and  on  the  face  of  the  patient,  from  which  a  plaster 
cast  or  mold  may  be  made  from  which  the  maker  of  pro- 
theses  can  work. 

With  the  model  in  hand  and  no  expert  on  protheses 
within  reach,  a  skillful  surgeon-dentist  could  easily  make 
a  vulcanized  rubber  nose,  which  may  then  be  painted  to 
suit. 

Some  method  of  attachment  must  be  provided  for, 
such  as  one  or  two  soft  rubber  plugs  or  stems  to  fit  into 


348     PLASTIC   AND    COSMETIC    SURGERY 

the  nasal  orifice  or  permanent  fixture  to  the  bridge  of  a 
pair  of  spectacles.  Gums  or  pastes  as  advised  with  aural 
protheses  may  be  of  service. 

Celluloid  protheses  should  never  be  used  because  of 
their  inflammable  nature;  furthermore,  they  are  easily 
damaged  or  cracked.  Wax  noses  are  of  little  use,  al- 
though resembling  the  normal  very  closely;  they  crack 
easily,  and  when  soiled  by  dust  or  friction  soon  have  to 
be  replaced  with  new  ones. 

The  following  list  of  authorities  shows  the  various 
materials  employed  by  them  for  nasal  protheses : 

Martin — Porcelain. 

Richter — Wood. 

Debout — Rubber  or  silver  covered  with  colored  wax. 

Mathieu — Aluminum. 

Charriere — Silver. 

NASAL  REPLANTING 

The  plastic  surgeon  is  often,  especially  in  later  years, 
called  upon  to  attend  to  traumatic  injuries  of  the  nose. 
Sometimes  there  is  a  total  severance  of  the  nose;  often 
a  partial  loss  or  injury,  practically  involving  a  loss  of  a 
part  of  the  organ.  Since  the  advent  of  the  automobile 
such  accidents  are  not  unusual. 

The  author  has  found  that  a  remarkable  history  lies 
back  of  the  replanting  of  parts  or  all  of  the  nose  when 
found  detached  by  accident  or  intent. 

If  the  part  cut  from  the  nose  or  face  has  been  not  too 
severely  bruised,  it  should  be  cleansed  gently  in  a  normal 
salt  solution  at  about  100°  F.,  and  be  sutured  in  place  as 
quickly  as  possible.  Partly  separated  sections  should  be 
treated  in  the  same  way.  It  is  remarkable  how  Nature 
will  take  care  of  these  traumatisms.  So  well  did  the 
executioners  in  India,  where  nasal  amputation  is  a  crimi- 
nal sentence,  know  this  that  they  destroyed  the  ampu- 
tated organ  by  fire,  so  that  the  victim  could  not  replant  it 
upon  himself, 


EHTNOPLASTY  349 

Clielius  successfully  replanted  a  nose  after  it  had  been 
severed  about  an  hour. 

Hoffacker  has  replanted  a  number  of  noses  cut  off  in 
the  duels  of  Heidelburg  students.  In  one  case  one  and  a 
half  hours  intervened  between  the  accident  and  the  oper- 
ation. 

In  partial  separations  about  the  nose  the  flap,  still 
hanging  by  a  slight  pedicle,  should  be  brought  in  place  by 
suture,  and  because  of  the  peculiar  hypertrophy  that 
always  follows  the  wounds  one  or  two  intraflap  su- 
tures should  be  employed  to  fix  the  part  centrally  to  the 
deeper  tissues,  if  any,  to  prevent  the  formation  of  clots 
that  are  liable  to  organize  and  encourage  such  enlarge- 
ment. 

Such  sutures  are  only  to  be  made  when  the  flap  is  of 
sufficient  size  to  necessitate  them.  If  the  hypertrophy 
or  hyperplasia  cannot  be  prevented  by  this  means  later 
cosmetic  operations  should  be  employed  to  make  the  parts 
heal  into  normal  contour. 

Blood  dressings  should  be  employed  after  the  parts 
have  been  fixed  by  a  number  of  fine  silk  sutures,  the  coap- 
tation  being  made  as  neatly  as  possible  to  get  the  best 
results. 

NASAL  TRANSPLANTING 

The  making  of  a  nose  or  part  thereof  from  a  nonpedi- 
cled  flap  of  skin  taken  from  the  patient  has  met  with  more 
or  less  success  in  the  remote  past,  but  of  later  years  such 
methods  have  fallen  into  disuse  because  of  the  many  and 
better  methods  of  modern  times  involving  the  use  of  flaps 
with  nutrient  pedicles. 

Branca  is  said  to  have  made  a  nose  for  a  patient  out 
of  the  skin  of  the  arm  of  a  slave. 

Velpeau  states  that  "  In  the  land  of  the  Pariahs  the 
men  in  power  had  no  scruples  in  having  the  nose  of  one 
of  their  subjects  cut  off  to  replace  the  lost  organ  of  an- 
other." 


Van  Helmont  is  said  to  have  made  a  nose  for  a  gentle- 
man from  the  skin  of  the  buttocks  of  a  street  porter. 

Bunger,  of  Marbourg,  in  1822  made  a  total  nose  from 
the  anterior  thigh. 

Several  surgeons  later  than  the  above  date  have  suc- 
cessfully restored  parts  of  the  nose  by  transplanting  skin 
flaps  from  remote  parts  of  the  body,  the  method  involved 
being  practically  what  is  now  accomplished  by  the  so- 
called  skin-grafting  methods  of  nonpedunculated  flaps 
heretofore  referred  to. 

While  for  small  defects  such  procedure  has  proven 
quite  successful,  the  employment  of  large  flaps  for  nasal 
reconstruction  has  been  exceedingly  discouraging,  al- 
though the  author  advises  trying  transplanting  of  such 
flaps  when  the  patient  hesitates  giving  up  sufficient  facial 
skin  for  rhinoplastic  purposes  for  fear  of  disfiguring 
scars,  or  when  there  are  untoward  reasons. 

In  such  event  there  is  only  the  secondary  wound  to  be 
considered  apart  from  the  death  of  the  flap,  and  the  minor 
operation  about  the  remains  of  the  nasal  organ  to  permit 
of  the  fixation  of  the  latter. 

A  thorough  and  practical  knowledge  of  skin  grafting 
is  of  the  greatest  necessity  to  the  surgeon,  because  he 
must  be  ready  to  cope  with  any  emergency  in  such  cases, 
and  thus  be  able  to  save  a  flap  graft  from  death  or  partial 
gangrene,  when  he  would  otherwise  fail. 

TOTAL  RHINOPLASTY 

PEDUNCULATED  FLAP  METHOD 

The  most  practical  and  safe  methods  of  rebuilding 
the  nasal  organ  have  been  those  in  which  flaps  having 
nutrient  pedicles  have  been  employed,  whether  these  flaps 
be  taken  from  the  skin  of  the  forehead,  cheek,  or  both. 
These  procedures  are  autoplasties,  and  may  be  grouped 
according  to  their  peculiar  differentiation  into  three 
classes,  as  follows: 


EHTNOPLASTY  351 

The  Indian  or  Hindu  Method,  in  which  the  flap  is  made 
from  the  forehead. 

The  French  Method,  in  which  the  flap  is  made  from 
the  tissue  about  the  borders  of  the  deformity. 

The  Italian  Method,  in  which  the  flap  is  taken  from 
some  distant  member  or  part  of  the  body. 

Furthermore,  there  are  the  combined  methods  of  one 
or  the  other  in  which  inverted  skin  flaps  are  used,  or  those 
lined  with  an  osseous  and  cartilaginous  support,  and  in 
some  rare  and  rather  unsuccessful  cases  by  metallic  sup- 
ports. 

The  Indian  or  Hindu  Method 

The  method  of  rebuilding  the  nose  by  taking  one  or 
two  flaps  from  the  forehead  dates  back  to  the  Koomas, 
from  whom  the  art  of  rhinoplasty  has  come  down  to  the 
present  time,  all  of  the  methods  of  to-day  involving  the 
utilization  of  the  pedunculated  flap  being  a  result  of  their 
early  surgical  ingenuity. 

Originally,  their  operation  consisted  of  cutting  an  oval 
flap,  having  its  pedicle  as  the  root  of  the  nose,  and  extend- 
ing over  the  forehead,  and  upward  vertically  into  the 
hair  line.  The  flap  thus  made  was  dissected  away  from 
the  bone  and  brought  down  by  twisting  it  to  the  extent  of 
a  hundred  and  eighty  degrees  on  its  pedicle  in  front  of 
the  nasal  deformity,  the  edges  of  which  had  been  pre- 
pared to  receive  it.  To  hold  the  flap  in  position  they  re- 
sorted to  some  kind  of  clay,  sutures  being  unknown  to 
them. 

The  pedicle  was  cut  after  the  flap  had  thoroughly 
united  t6  the  freshened  borders  of  the  deformed  nose. 

The  steps  of  the  operation  as  performed  by  them  are 
shown  in  Figs.  314,  315,  and  316. 

Naturally,  many  improvements  in  the  above  method 
have  been  evolved,  principally  to  overcome  the  extreme 
and  injurious  torsion  of  the  pedicle,  and  from  the  desire 
on  the  part  of  the  surgeon  to  bring  about  a  better  cos- 


352      PLASTIC    AND    COSMETIC    SURGERY 

metic  result.  Therefore,  not  only  the  position  of  the 
pedicle  and  its  shape  were  altered,  but  also  the  size  of 
the  flap  itself,  as  will  be  shown  in  the  specific  methods  of 
the  various  authorities  mentioned  hereafter. 

The  author  does  not  consider  it  necessary  to  go  into 
chronological  details  of  the  evolvement  of  the  art,  and 
begs  the  surgeon  to  be  content  to  learn  of  those  opera- 
tions and  methods  that  have  given  the  best  result. 


FIG.  314. 


FIG.  315. 
KOOMAS  METHOD. 


FIG.  316. 


Where  one  surgeon  has  changed  his  incisions  in  the 
slightest  direction  and  another  has  advised  increasing  the 
number  of  sutures  is  of  little  import  to  the  operator  of 
to-day ;  the  gist  of  it  all  is  the  successful  method  for  the 
successful  outcome. 

The  first  to  be  considered  will  be  those  methods 
wherein  the  vertical  direction  and  the  position  of  the 
pedicle  have  been  similar  to  that  of  the  Koomas.  It  will 
therein  be  noted  that  the  principal  change  has  been  in 
the  formation  of  the  distal  end  of  the  flap  with  the  object 
solely  of  forming  a  better  base  to  the  nose. 

Graeffe  Method. — The  flap  was  made  in  the  shape  of  a 
heart  with  a  rectangular  addition  at  its  upper  or  scalp 
border.  The  pedicle  is  made,  to  lie  between  the  inner 
limitations  of  the  eyebrows  (see  Fig.  317). 


RHINOPLASTY 


353 


The  flap  is  twisted  into  position  and  sutured  into  the 
freshened  remains  of  the  nose,  the  pedicle  being  cut  at 
a  second  operation  after 
the  flap  has  healed  into 
place,  which  was  about 
the  tenth  day. 

Delpech  Method. — The 
shape  of  the  frontal  flap 
was  cut  in  the  form  of  a 
trident,  as  shown  in  Fig. 
318. 

The  object  of  the  ar- 
rangement was  to  give  a 
rimlike  lining  to  the  two 
nostrils,  the  raw  sur- 
faces of  the  outer  points 
being  brought  into  con- 
tact with  each  other. 

He  also  hollowed  out 
a  groove  at  the  root  of 
the  nose,  to  better  ac- 
commodate the  pedicle 

when  twisted.  The  steps  are  shown  in  Figs.  319  to 
321.  The  pedicle  was  later  severed  when  the  conditions 
warranted  it. 

Method  of  Lisfranc. — Lisfranc  conceived  the  idea  that 
if  he  carried  down  the  one  incision  for  the  flap  at 
the  root  of  the  nose  somewhat  lower  than  the  other 
he  would  overcome  some  of  the  torsion  at  this  point. 
This  he  consequently  did,  making  the  left  incision  half 
an  inch  lower  than  the  right.  The  lateral  incisions 
ascend  at  an  angle  of  forty-five  degrees  (see  Fig.  322), 
uniting  in  rectangular  form  at  the  scalp  line,  as 
shown,  the  rectangle  of  skin  being  utilized  to  make  the 
subseptum. 

Instead  of  sutures  he  dissected  up  the  old  nasal  bor- 
ders and  slid  the  flap  borders  into  this  groovelike  ar- 

24 


FIG.  317. — GRAEFFE  METHOD. 


FIG.  318. 


FIG.  319. 


FIG.  321. 


RHINOPLASTY 


355 


rangement,  holding  it  in  place  with  the  aid  of  sticking 
plasters. 

With  the  above  method  the  pedicle  was  allowed  to 
remain  intact.  Fig.  323  shows  the  position  of  the  flap, 
and  the  treatment  of  the  subseptal  section. 


FIG.  322. 


FIG.  323. 


LISFRANC  METHOD. 


Labat  Method. — Labat  uses  a  frontal  flap  shaped  as  in 
Fig.  324.  The  left  bordering  incision  is  carried  down  one 
half  inch  below  the  point  of  beginning  on  the  right  and 
carried  downward  in  such  manner  that  its  lower  point  lies 
in  a  line  with  that  of  the  right  above  it. 

The  object  of  this  was  to  overcome  torsion,  and,  where 
obtainable,  the  small  triangle  of  healthy  tissue  at  the  root 
of  the  nose,  as  shown  in  the  illustration,  was  dissected 
off  from  above  downward,  and  turned  downward  with 
the  cutaneous  side  facing  the  nasal  chasm  and  its  dis- 
sected side  facing  that  of  the  flap.  He  avoids  injury  to 
the  angular  artery,  as  should  be  done  in  all  cases.  The 
pedicle  was  replaced  at  a  second  operation. 


356      PLASTIC    AND    COSMETIC    SURGERY 

Keegan  Method. — Utilized  a  flap,  shaped  as  in  Fig.  325. 
The  pedicle  occupies  the  internal  angle  of  the  eye,  care 
being  taken  to  preserve  the  angular  artery.  The  flap  is 
mapped  out  obliquely,  not  perpendicularly.  To  get  the 
best  results  he  advises  pasting  a  paper  model  upon  the 
forehead  to  guide  the  operator  in  making  the  flap,  which 
includes  all  the  tissue  down  to  the  periosteum.  Ilorse- 


FIG.  324. — LABAT  METHOD. 


FIG.  325. — KEEGAN  METHOD. 


hair  sutures  are  employed  to  approximate  the  parts  ac- 
curately. The  pedicle  is  divided  in  about  twenty  days, 
and  a  wedge-shaped  piece  of  skin  is  excised  at  the  root 
of  the  nose  to  prevent  the  tuberosity  at  this  point  of 
the  new  nose,  so  commonly  observed  with  Indian-flap 
methods. 

Duberwitsky  Method. — The  flap  at  its  root  resembles  that 
of  Labat,  but  at  its  superior  border  it  formed  an  oval  with 
an  elongated  point  running  into  the  hair  line,  which  he 
divided,  as  shown  in  Fig.  326,  to  form  the  subseptum  and 
nasal  wings. 


357 


At  the  root  the  pedicle  was  about  half  an  inch  wide 
made  in  the  oblique. 

The  middle  section  of  the  superior  pointlike  projec- 
tion and  intended  for  the  subseptum  was  folded  upon 
itself  or  doubled,  as  it  were,  to  give  support  to  the  nasal 
point.  The  same  was  done  with  the  alar  or  lateral  sec- 
tions, so  as  to  line  the  nares  with  epitheliar  surface 
to  prevent  contraction.  The  lower  part  of  the  nose 
was  fixed  into  position  by  a  harelip  pin  inserted  trans- 
versely after  all  parts  of  the  flap  had  been  sutured  into 
place. 

Dieffenbach  Method. — The  flap  is  cut  very  much  like  that 
advised  by  Lisfranc,  being  wider  only  at  its  upper  ex- 
tremity, as  shown  in  Fig.  327. 


FIG.  326. — DUBEHWITSKY  METHOD. 


FIG.  327. — DIEFFENBACH  METHOD. 


He  advocates  removing  the  remains  of  the  old 
nose,  almost  circumscribing  the  nose,  as  shown  in  the 
illustration,  except  for  the  deep  linear  incision  at 
the  base  of  the  nose  on  a  level  with  the  oval  fissure, 


358      PLASTIC    AND    COSMETIC    SURGERY 

leaving  a  bridge  of  skin  at  either  angle  into  which  the 
square  or  septal  part  of  the  superior  frontal  flap  is 
affixed. 

The  flap  is  made  so  that  the  right  oblique  line  lies  an 
inch  above  that  of  the  left,  the  latter  incision  running 
into  the  angle  formed  at  the  root  of  the  old  nose  caused 
by  the  ablation. 

Von  Ammon  Method. — The  flap  is  cut  at  its  superior 
border,  similar  to  that  of  Keegan,  but  made  in  the  per- 


FIG.  328. — VON  AMMON  METHOD. 


FIG.  329. — AUVERT  METHOD. 


pendicular ;  the  point  of  beginning,  at  the  end  of  the  right 
eyebrow,  lies  about  an  inch  above  the  end  of  the  incision 
of  the  opposite  side,  but  in  line  with  it  (Fig.  328).  The 
same  method  of  removing  the  remains  of  the  old  nose 
advocated  by  Dieffenbach  is  followed  as  well  as  the 
lobial  incision  to  receive  the  septal  section. 

The  shape  of  this  flap  permits  of  bringing  the  sec- 
ondary wound  on  the  forehead  more  readily  than  where 
square  exsections  are  resorted  to. 


BHINOPLASTY 


359 


Auvert  Method. — Like  the  method  of  Keegan,  the  frontal 
flap  is  made  at  an  angle  of  forty-five  degrees  instead  of 
the  perpendicular,  the  flap  being  cut  to  the  left  of  the 
median  line.  Its  outline  is  shown  in  Fig.  329,  and  differs 
little  at  its  superior  ex- 
tremity from  that  of 
Labat,  except  that  it  is 
made  longer  and  nar- 
rower. The  left  lateral 
incision  runs  into  the  su- 
perior border  of  the  old 
nose  at  the  median  line. 

Von  Langenbeck  Method. 
—The  flap  is  fashioned 
like  that  of  Duberwitsky, 
but  the  left  lateral  incis- 
ion enters  the  remains  of 
the  old  nose,  as  Dieffen- 
bach  advised.  The  supe- 
rior border  was  shaped, 
as  shown  in  Fig.  330, 

to   form  the   al8B  and  COl-       pIG.  330.— VON  LANGENBECK  METHOD. 

umna. 

Petrali  Method. — The  shape  of  the  flap  is  cut  in  ovate 
form  with  its  rounded  base  near  the  hair  line  of  the  fore- 
head. Petrali  likens  it  to  the  form  of  the  mulberry  leaf. 
The  left  lateral  incision  dips  down  into  the  median  line 
of  the  old  deformity  at  its  upper  border. 

The  flap,  after  having  been  cut  free,  is  folded  upon 
itself  along  the  median  line,  bringing  the  raw  surfaces 
together  along  the  dorsum  of  the  new  nose,  thus  giving 
body  to  the  whole  anterior  nasal  line.  Presumably  he 
introduces  several  sutures  through  the  side  of  the  flap  to 
facilitate  union  along  this  line. 

The  method  is  illustrated  in  Figs.  331  and  332. 

Forque  Method. — Herein  the  right  lateral  incision  of  the 
frontal  flap  is  begun  at  a  point  above  and  corresponding 


360     PLASTIC    AND    COSMETIC    SURGERY 


to  the  middle  of  the  eyebrow.  The  base  is  fashioned  as 
shown  in  Fig.  333,  and  the  left  lateral  incision  is  carried 
down  to  the  median  line  of  the  old  nasal  defect,  coming 
within  the  inner  border  of  the  eyebrow. 

D'Alguie  Method. — This  author  conceived  the  idea  of  fur- 
ther relieving  the  torsion  of  the  pedicle  by  making  the 
frontal  flap  transverse  along  the  forehead,  instead  of 
perpendicular. 

The  incision  at  the  root  of  the  nose  is  on  a  level  and 
in  line  with  the  inner  ends  of  the  eyebrows.  The  left  lat- 


FIG.  331. 


PETRALI  METHOD. 


FIG.  332. 


eral  incision  is  made  to  lie  just  above  the  eyebrow  and  the 
right  sweeps  upward  and  outward,  as  shown  in  Fig.  334. 

The  base  is  made  with  a  rectangular  projection  to 
form  the  columna. 

Landreau  Method. — The  direction  of  the  frontal  flap  is 
transverse,  but  the  root  of  pedicle,  instead  of  having  a 
downward  direction,  is  so  cut  as  to  have  its  attachment 
upward,  as  shown  in  Fig.  335.  This  position  of  the 
pedicle  thus  overcomes  to  a  great  extent  the  torsion  .at 
this  point.  The  flap  must  be  cut  somewhat  longer  in  its 


FIG.  333. — FORQUE  METHOD. 


FIG.  334. — D'ALGUIE  METHOD. 


FIG.  335. — LANDREAU  METHOD. 


FIG.  336. — VON  LANGENBECK  METHOD. 
361 


362      PLASTIC    AND    COSMETIC    SUBGERY 

transverse  axis  to  allow  for  the  higher  position  of  the 
pedicle  on  the  forehead. 

The  distal  end  of  the  flap  is  trident-shaped,  as  shown. 

Langenbeck  Method. — The  flap  is  cut  on  an  oblique  line 
along  its  left  border,  running  the  incision  down  and 
across  the  root  of  the  nose  to  the  right  while  the  right  in- 
cision begins  just  under  the  eyebrow  and  extends  less  ob- 
liquely upward,  as  shown  in  Fig.  336.  The  base  of  the 
pedicle  is  fashioned  as  shown.  The  bordering  remains  of 
the  old  nose  are  removed. 

In  another  operation  by  the  same  operator  the  right 
incision  was  begun  at  a  point  above  the  eyebrow  and  car- 
ried transversely  along  to  the  rising  point  of  the  lateral. 


FIG.  337. — VON  LANGENBECK  METHOD. 


FIG.  338. — SZYMANOWSKI  METHOD. 


The  left  lateral  incision  was  so  made  that  it  left  an  area 
of  skin  over  the  root  of  the  nose,  as  shown  in  Fig.  337, 
which  he  dissected  away,  giving  that  part  of  the  flap  to 
cover  it  an  opportunity  to  adhere,  at  the  same  time  fur- 
nishing a  nourishing  area  for  its  future  life. 


RHINOPLASTY  363 

Szymanowski  Method. — The  flap  is  formed  as  shown  in 
Fig.  338,  the  pedicle  having  its  upper  incision  just  below 
the  end  of  the  right  eyebrow  and  the  lower  below  the 
inner  canthus  on  a  line  with  the  first,  giving  it  an  oblique 
position. 

Just  below  the  curvature  of  the  basal  incision  two 
short  incisions  are  made  on  either  side  into  the  forehead 
tissue  with  a  view  of  rendering  more  flexible  the  skin  to 
be  utilized  in  correcting  the  secondary  wound.  The  mar- 
gin of  the  old  nose  is  freshened. 

Labat,  Blasius,  Linhart  Method, — These  operators  per- 
formed their  operations  in  two  sittings.  In  the  first  the 
incisions  were  so  made  at  the  base  as  to  permit  of  that 
part  of  the  flap  intended  for  the  rim  of  the  nares  to  be 
tucked  in,  as  it  were,  where  these  two  triangular  little 
folds  were  held  in  place  by  silk  suture.  When  the  parts 
had  become  thoroughly  united,  or  at  the  second  sitting, 
the  entire  flap  was  cut  away  and  brought  into  place  for 
the  new  nose.  The  object  of  this  procedure  was  to  give 
body  to  the  wings  of  the  nose  and  to  overcome  the  con- 
sequent curling  and  contraction  of  the  skin  so  commonly 
found  with  the  single  sitting  operation. 

This  step  marked  the  first  advancement  toward  at- 
taining much  more  successful  results  in  total  rhinoplasty 
by  using  skin-lined  flaps,  which  not  only  added  to  the 
better  nutriment  to  the  part,  but  also  gave  support  and 
firmness  to  the  new  organ. 

The  French  Method 

This  method,  per  se,  is  not  in  itself  sufficient  to  bring 
about  a  satisfactory  result.  The  fundamental  principle 
is  that  of  the  sliding  flap  of  Celsus,  and  in  which  the  two 
flaps  intended  to  form  the  new  nose  are  taken  from  the 
tissue  of  the  cheek  at  either  side  of  the  remains  of  the 
old  nose. 

The  total  outcome  is  simply  to  bring  before  the  open- 
ing a  curtain  of  skin  with  a  median  scar  running  from 


the  root  to  the  lobule,  which  in  itself  is  sufficient  upon 
contraction  to  mar  the  result ;  furthermore,  there  are  the 
two  lateral  wounds  which  have  to  be  covered  by  skin 
grafts  which,  upon  healing,  have  their  tension  of  contrac- 
tion, added  to  that  of  the  median  scar,  with  the  result  that 
the  anterior  nose  becomes  flattened  and  ugly,  practically 
amounting  only  to  an  unevenly  contracted  curtain  of 
marred  skin. 

The  author  would  not  advise  resorting  to  such  method, 
but,  owing  to  the  fact  that  a  step  in  the  advancement  of 
the  art  was  conceived  under  this  particular  method,  space 
is  given  to  the  subject.  This  step,  first  introduced  by 
Nelaton,  consisted  of  allowing  all  of  the  cicatricial  tis- 
sue of  the  old  nose  to  remain  with  which  the  new  nose 
could  be  built.  As  the  possibility  of  this  is  rare  in  total 
rhinoplastic  cases,  the  method  is  more  useful  in  partial 
rhinoplastics,  where  it  forms  an  important  factor,  as 
will  be  shown  later  under  that  subdivision. 

Nelaton  Method. — Two  lateral  flaps  of  triangular  form, 
having  their  pedicles  below  the  internal  canthi,  are  cut 
from  the  cheeks,  each  flap  containing  all  of  the  remains 
of  the  old  nose.  The  entire  inner  borders  of  these  flaps 
were  freshened  throughout  their  whole  thickness. 

In  making  the  flaps,  dissection  is  made  down  and 
through  the  periosteum,  thus  giving  firmness  and  thick- 
ness to  the  new  nose.  The  flaps  are  slid  forward  and 
sutured  along  the  median  line,  leaving  a  triangular  wound 
of  the  cheek  on  either  side,  as  shown  in  Fig.  339. 

To  keep  the  raw  surfaces  in  contact  with  the  newly 
dissected  area  and  to  retain  the  nose  in  place  as  far  as 
possible,  a  silver  pin  is  inserted  through  the  base  of  the 
new  nose,  going  through  the  skin  and  remains  of  the 
old  nose.  It  should  be  of  sufficient  length  to  permit  hold- 
ing a  disk  of  cork  at  either  end,  beyond  the  skin  and 
for  the  retention  of  the  metal  ring  ends  of  a  hook  bent  in 
inverted  U-shape.  The  diameter  of  the  latter  bent  wire  is 
equal  to  that  of  the  pin. 


365 


Ho  claims  for  his  method  a  perfect  and  fixed  cica- 
trization of  the  newly  placed  parts. 

Heuter  Method. — The  cheek  flaps  are  cut  from  the 
cheeks,  as  shown  in  Fig.  340,  leaving  intact  a  triangular 


FIG.  339. — NELATON  METHOD. 


FIG.  340. — HEUTEH  METHOD. 


piece  of  skin  with  the  object  of  giving  support  to  the 
new  nose.  The  inner  and  upper  borders  of  the  two  flaps 
were  stitched  to  the  rim  of  this  triangle,  and  then  along 
the  median  line.  The  flaps  are  not  made  to  include  the 
periosteum,  as  in  Ne- 
laton's  method.  The 
results  thus  obtained 
are  not  equal  to  the 
latter's  procedure. 

Biirow  Method. — The 
cheek  flaps  are  made 
as  in  Fig.  341.  The  pro- 
jection intended  for  the 
subseptum  is  an  elon- 
gated strip  at  the  in- 
ferior border  and  inner  FIG.  341.— BUROW  METHOD. 
angle  of  the  left  flap. 

The  shaded  triangles  at  either  extremity  of  the  outer 
incisions  show  the  removal  of  the  skin  at  these  points, 
to  facilitate  sliding  of  the  flaps,  adding,  however,  to  the 


366     PLASTIC   AND   COSMETIC   SURGERY 


extent  of  cicatricial  contraction  upon  final  healing,  with 
the  resultant  flattening1  of  the  new  nose.  The  lobular 
prominence  takes  an  upward  position  eventually,  and  al- 
together the  extensive  secondary  wounds  and  the  effect 
of  their  behavior  does  not  warrant  the  use  of  this  method. 
Szymanowski  Method, — His  method  is  an  improvement 
on  that  of  Biirow.  The  flaps,  inclusive  of  considerable 
cellular  tissue,  are  fashioned  in  Fig.  342,  except  under 

the  two  narrow  ex- 
tension flaps,  which 
are  to  be  utilized  in 
building  up  the  sub- 
septum.  Their  raw 
surfaces  are  sutured 
together  with  silk. 
The  flaps  are  united 
along  the  median 
line. 

If  the  tissue 
from  the  cheeks  do 
not  permit  of  free 

sliding  forward  of  the  flaps,  further  incisions  shown  by 
the  dotted  lines  over  each  malar  prominence  are  made. 
The  skin  of  the  shaded  irregular  areas  on  either  side  is 
removed,  as  in  the  Biirow  method. 

Serre  Method— The  flaps  are  made  to  either  side  of  the 
remains  of  the  old  nose,  each  leaving  its  pedicle  about 
one  fourth  inch  below  the  inner  canthus  of  the  eye.  The 
flaps  were  cut  rather  obliquely,  their  bases  extending 
somewhat  below  the  nasal  orifices.  The  remaining  skin 
of  the  latter  was  dissected  downward  and  folded  down 
upon  the  median  third  of  the  lip.  If  cut  in  two  sections 
their  inner  borders  were  sutured  so  that  their  raw  sur- 
faces faced  each  other.  The  object  of  the  latter  step 
was  to  form  the  subseptum,  according  to  Lisfranc.  The 
sections  of  skin  lying  with  their  bases  on  a  level  with 
the  nasal  orifices  were  dissected  downward  and  united 


FIG.  342. — SZYMANOWSKI  METHOD. 


BHINOPLASTY 


367 


in  the  median  line  to  assist  in  forming  the  end  of  the 
nose.  All  along  the  borders  of  the  old  nose  were  also 
dissected  up  where  possible  and  folded  inward,  so  that 
their  raw  surfaces  would  adhere  to  the  new  dorsum  of 
the  nose,  and  thus  give  it  stability  and  form.  These 
pieces  of  skin  were  united  at  the  median  line  when 
possible. 

The  cheek  flaps  with  indented  bases  were  now  brought 
forward  and  united,  as  shown  in  Fig.  343.  The  skin 
of  the  cheeks  was  dissected  up  to  the  extent  of  the  dotted 
line  in  the  former  illustration,  and  when  necessary  two 
lower  curved  incisions  were  made  to  permit  of  free  slid- 
ing. The  skin  of  the  cheeks  was  retained  by  three  sutures 


FIG.  343. 


SERRE  METHOD. 


at  either  side,  as  shown  in  Fig.  344.  The  subseptum 
may  be  made  at  the  same  sitting,  or  at  a  later  operation. 

Byrne  Method. — The  procedure  is  very  like  that  of  Heu- 
ter,  except  that  the  somewhat  curved  line  making  the 
inner  borders  of  the  flaps  extended  over  the  root  of  the 
old  nose.  The  lower  ends  or  bases  of  the  two  cheek  flaps 
were  stitched  around  and  to  the  orifice  to  form  the  end 
of  the  nose,  rubber  tubes  being  used  to  form  the  nostrils, 
where  they  were  retained  until  healing  was  complete. 

Blasius  Method. — He  forms  the  cheek  flaps  in  triangular 
form,  including  all  of  the  tissue  making  up  the  buccal 


368     PLASTIC    AND    COSMETIC    SURGERY 

cavity.  The  outer  or  cheek  incision  is  made  through  all 
of  the  tissue  and  extends  to  a  point  corresponding  to  a 
point  a  given  distance  beyond  the  angle  of  the  mouth. 
The  inner  incision  is  made  from  a  point  just  below  the 
angle  of  the  ala  downward  and  through  the  thickness 
of  the  lip.  A  third  incision  unites  the  angle  of  the  mouth 
with  the  outer  incision.  Both  cheek  flaps  are  made  alike, 
each  remaining  attached  along  all  of  the  remains  of  the 
old  nose.  They  are  now  raised  upward  and  inward,  with 
their  mucosa  facing  outward,  and  united  along  the  me- 
dian line.  The  raw  cheek  borders  are  now  brought  for- 
ward and  held  in  place  by  suturing  them  at  either  side 
to  the  remaining  rectangular  flap  of  the  upper  lip.  The 
formation  of  the  subseptum  is  left  for  a  second  sitting. 
This  method  is  not  only  too  extensive,  but  too  disfigur- 
ing to  make  its  employment  practicable.  The  mucous 
membrane  would,  of  course,  in  time  take  on  the  function 
and  appearance  of  skin,  but  the  shape  of  the  mouth  never 
assumes  a  normal  form,  especially  since  there  is  quite 
a  loss  of  the  vermilion  border  at  either  side  which  is 
raised  upward  with  the  cheek  flaps  to  assist  in  forming 
the  base  of  the  nose. 

Maisonneuve  Method. — Where  there  is  more  or  less  oc- 
clusion of  the  nares  and  yet  an  integumentary  covering 
corresponding  to  the  nose,  as  it  might  rarely  be  in  con- 
genital cases,  Maissonneuve  utilizes  the  sliding  flap  meth- 
od to  overcome  the  abnormality.  In  the  case  presented, 
the  nasal  orifices  were  hardly  three  sixty-fourths  of  an 
inch  in  diameter  and  about  one  inch  apart.  The  correc- 
tion was  accomplished  as  follows,  and  shown  in  Fig.  345 : 
An  incision  was  made  transversely  outward  from  each 
nostril,  then  two  converging  incisions  were  made  from 
both  nares  downward,  meeting  at  the  vermilion  border 
of  the  lip  in  the  form  of  a  V,  which  were  made  to  include 
the  whole  thickness  of  the  lip.  This  flap  was  brought 
upward  to  form  the  subseptum.  The  skin  to  form  the 
nasal  lobule  was  now  slid  forward  from  either  end  of  the 


ETIINOPLASTY 


369 


incision  and  the  subseptum  sutured  in  place.  Rubber 
tubes  were  employed  to  keep  the  nares  distended  and 
permit  of  the  wings  of  the  nose  to  form. 


FIG.  345. 


Fio.  346. 


MAISONNEUVE  METHOD. 


The  defect  in  the  upper  lip  was  brought  together  as 
in  a  median  harelip  operation,  the  parts  appearing  after 
operation  as  illustrated  in  Fig.  346. 

The  Italian  Method 

In  this  classification  of  total  rhinoplasty  the  skin  flap 
is  taken  from  another  part  of  the  body  and  not  from 
the  face.  The  integument  of  the  arm  is  usually  employed, 
the  pedicle  remaining  intact  until  the  flap  has  healed  into 
place. 

The  method  has  been  accredited  to  the  Italian  author- 
surgeon  Tagliacozzi,  but  it  was  practiced  long  before  his 
time;  yet  he  was  the  first  to  fully  describe  the  steps  of 
the  successful  operation.  It  has  been  referred  to  quite 
fully  under  skin  grafting. 

The  flap  having  an  attached  pedicle  is  cut  from  the 
entire  thickness  of  the  skin  of  the  arm.  The  free  end 
of  the  flap  is  sutured  to  the  freshened  borders  of  the  old 

25 


370     PLASTIC    AND    COSMETIC    SURGERY 

nose,  and  the  arm  is  held  in  place  until  union  has  been 
established,  when  the  pedicle  is  cut.  There  are  no  special 
advantages  in  this  method,  since  the  outcome  is  no  better 
than  that  obtained  with  the  Indian  method;  at  best  the 
result  is  merely  the  curtain  of  skin  covering  the  defect, 
with  the  one  thing  in  its  favor — the  avoidance  of  the 
frontal  scar.  Against  this  is  the  great  discomfort  the 
patient  must  suffer  in  having  his  arm  retained  in  the 
necessary  position  to  prevent  movement  and  strain  on 
the  flap,  to  which  may  be  added  the  danger  of  embolism 
occasioned  by  freeing  the  arm  at  the  time  the  pedicle  is 
cut.  There  is  also  difficulty  of  properly  dressing  the 
wounds,  owing  to  the  constrained  position  which  conse- 
quently invite  sepsis  and  imperfect  healing.  Hence,  for 
total  rhinoplasty,  this  method  may  be  termed  unsatis- 
factory; yet  for  certain  partial  rhinoplastic  results  it 
supersedes  all  other  methods,  as  will  be  hereinafter 
shown. 

To  make  the  flap  a  pattern  is  laid  upon  the  skin,  from 
which  it  is  to  be  made ;  it  should  be  one  third  larger  than 
the  actual  size  of  flap  needed,  to  allow  for  contraction. 
The  incisions  should  go  through  the  entire  thickness  of 
the  skin,  leaving  an  attachment  or  pedicle,  what  in  this 
case  would  be  the  part  of  the  flap  intended  for  the  base 
of  the  nose,  and  directly  opposite  to  those  described  here- 
tofore. 

The  flap  may  be  sutured  in  place  immediately  after 
the  cutting,  or  it  may  be  allowed  to  remain  upon  the  arm 
until  contraction  has  taken  place  in  the  flap,  or  the  flap 
may  first  be  modeled  into  nose  shape  and  then  sutured 
upon  the  freshened  margins  of  the  old  nose. 

The  arm  must  in  any  of  these  methods  be  held  in  place 
during  the  days  required  to  have  the  flap  heal  or  unite 
with  the  facial  tissue.  The  various  operators  have  de- 
vised means  to  accomplish  this.  There  is  the  linen  net- 
work of  bandages  of  Tagliacozzi,  the  harness  of  Berger, 
the  starched  linen  and  book -board  affair  of  Sedillot,  the 


RHINOPLASTY  371 

one-piece  suit  of  Lalenzowski,  the  leather  sleeve  and  hel- 
met of  Graefe  and  Delpech  and  many  others. 

Having-  determined  upon  the  method  to  be  followed 
in  securing  the  flap,  the  surgeon  is  advised  to  consider 
such  apparatus  as  he  may  be  able  to  procure  to  retain 
the  parts,  or  to  use  his  own  ingenuity  to  construct  one 
of  plaster-of-Paris  bandages  to  meet  the  requirements  of 
the  case  at  not  only  less  expense,  but  with  greater  comfort 
to  the  patient.  At  best,  any  apparatus  employed  will  do 
little  to  overcome  the  agony  of  the  retained  member, 
which  must  be  held  in  position. 

Various  operators  give  this  period  between  six  and 
twenty  days.  The  apparatus  should  be  so  constructed 
that  dressings  can  be  easily  made  without  discomfort  to 
the  patient,  and  without  doing  damage  to  the  parts,  and 
also  to  expose  the  face  of  the  patient  as  much  as  possible. 
The  various  operations  employed  to  perform  total  rhino- 
plasty  by  the  Italian  method  may  now  be  considered. 

Tagliacozzi  Method. — This  surgeon  resorted  to  four  steps 
to  accomplish  his  operations,  which  were: 

I.  Massage  of  or  stretching  the  skin  of  the  part  from 
which  the  flap  is  to  be  made. 

II.  Cutting  the  flap,  and  allowing  the  same  to  cica- 
trize. 

III.  Freshening  the  flap  and  suturing  in  place,  and 
use  of  apparatus. 

IV.  Cutting  the  pedicle  and  making  the  subseptum. 

The  various  details  of  these  steps  should  be  consid- 
ered here,  since  the  methods  are  practically  the  same 
for  all  other  operations  of  this  kind,  except  in  certain 
particulars  as  to  time  and  mode  of  procedure. 

I.  Massaging  the  tissue  of  the  arm  to  render  it  sup- 
ple.   This  is  of  some  consequence,  in  some  cases,  where 
the  skin  is  tense,  but  requires  no  especial  description. 

II.  He  then  compressed  a  fold  of  the  skin  with  a  large 
forceps  at  the  lower  half  of  the  biceps.    Upon  opening 
these  forceps  he  forced  a  bistoury  under  the  skin  fold 


372     PLASTIC    AND    COSMETIC    SURGERY 

and  cut  down  toward  the  elbow-joint  a  distance  sufficient 
to  form  a  flap.  This  gave  him  a  piece  of  raised  skin, 
attached  at  either  end,  double  the  size  of  that  required 
to  make  the  nose.  Under  this  he  introduced  linen  mesh 
dressings  in  the  form  of  a  seton,  with  the  object  of  irri- 
tating the  skin  to  encourage  the  circulation,  and  render 
it  thicker  by  consequent  suppurations  and  granulations. 
This  was  continued  for  fifteen  days,  when  the  skin  was 
detached  at  its  upper  end,  leaving  it  attached  by  the 
lower  or  wider  pedicle  intended  for  the  base  of  the  nose. 
The  flap  was  now  turned  down  and  both  flap  and  wound 
were  allowed  to  cicatrize. 

III.  When  the  flap  had  become  dry  he  fitted  the  linen 
bandage  apparatus  to  retain  the  arm.    Then  the  borders 
of  the  old  nose  were  freshened.     Thereafter  he  cut  a 
paper  pattern  as  a  model  for  the  new  nose,  upon  which 
the  margins  and  shape  of  the  flap  were  cut.     The  flap 
was  finally  sutured  in  place,  and  the  apparatus  was  tight- 
ened to  prevent  movement  of  the  parts. 

IV.  After  twenty  days  he  cut  the  pedicle.    The  latter 
was  then  cut  into,  to  divide  it  in  three  parts,  which  he 
formed  into  the  subseptum  and  nasal  wings,  which  were 
sutured  in  place,  metal  tubes  being  employed  to  keep  the 
nares  open. 

Dieffenbach  Method. — This  surgeon  followed  seven  steps 
to  complete  the  operation,  as  follows: 

I.  The  pattern  of  the  new  nose,  cut  one  third  larger, 
is  fixed  upon  the  skin  of  the  arm,  with  the  basic  pedicle 
just  above  the  fold  of  the  elbow.    Skin  is  now  raised  suffi- 
ciently to  permit  of  its  being  incised,  the  incisions  being 
made  laterally,  as  shown  in  the  dark  lines  in  Fig.  347. 

This  gives  a  triangular  flap,  the  apex  lying  upon  the 
biceps  and  having  two  adherent  pedicles  at  apex  and  base. 

The  base  is  now  incised  at  one  angle,  transversely  and 
again  vertically,  as  shown.  This  incision  liberates  the 
part  of  the  flap  intended  for  one  of  the  ala  of  the  nose. 

II.  Diachylon  plasters  are  placed  under  the  flap  to 


RHINOPLASTY 


373 


contract  the  arm  wound  immediately  the  bleeding  has 
been  arrested.  The  free  angle  of  the  base  of  the  flap  is 
now  turned  inward  and  under  the  attached  part  of  the 
flap,  as  in  Fig.  348,  so  that  its  margin  protrudes  from 
the  other  lateral  incision,  and  its  skin  surface  lying  above 


FIG.  347.  FIG.  348.  FIG.  349. 

DlEFFENBACH    AltM-FLAP    METHOD. 

the  plaster.  The  edges  of  the  flap  are  now  stitched  to- 
gether, and  the  flap  is  allowed  to  lie  cushionlike  upon 
itself  while  the  arm  wound  heals.  This  requires  about 
six  weeks. 

III.  The  holding  of  the  flap  cushion  in  place  by  the 
use  of  splints  of  leather  held  in  place  by  three  needles. 
The  latter  are  moved  about,  as  the  shape  of  the  cushion 
becomes  modeled,  about  every  three  weeks.    The  process 
ends  when  cicatrization  of  the  flap  or  the  newly  formed 
nose   has   been   accomplished,    shown  by  firmness   and 
contour. 

IV.  The  margins  of  the  old  nose  are  freshened;  the 
lateral  incisions  extend  to  the  root  of  the  nose,  where 


they  are  united  with  an  upward  convex  incision.  The 
skin  is  well  raised,  gutterlike,  from  the  deeper  tissue,  to 
assure  of  the  best  vascularity. 

V.  The  upper  or  apex  pedicle  of  the  flap  on  the  arm 
is  cut  (see  Fig.  349),  and  the  thickened  roll  of  skin,  or 
what  may  now  be  termed  the  new  nose,  is  turned  down 
toward  the  elbow.    It  is  divided  along  the  line  where  the 
two  margins  of  skin  had  been  sutured;  in  other  words, 
it  is  laid  open  longitudinally. 

VI.  The  nose  thus  prepared  is  brought  into  place  be- 
fore the  freshened  margins  of  the  old  nose  and  is  sutured 
into  place  beginning  at  the  root  before  the  sides  are 
coapted. 

VII.  At  the  end  of  fifteen  days  the  pedicle  attaching 
the  nose  to  the  arm  is  severed,  the  angle  for  the  wing 
being  cut  slightly  larger  than  that  of  the  other  side,  which 
by  this  time  has,  of  course,  undergone  full  contraction. 
The  subseptum  is  made  out  of  the   square  projection 
folded  upon  itself,  raw  surfaces  facing,  and  is  brought 
into  place  by  suturing  it  into  an  incision  made  in  the  lip 
at  the  required  point. 

Graefe  Method. — This  surgeon  devotes  six  steps  to  his 
operation,  as  follows: 

I.  The  borders  of  the  old  nose  are  freshened. 

II.  Sutures  are  passed  through  the  raised  skin  of  the 
borders  of  the  old  nose. 

III.  The  flap  is  cut  from  the  arm  after  a  pattern  made 
one  fourth  larger  than  the  new  nose  required,  leaving 
it  attached  by  the  small  pedicle  intended  for  the  sub- 
septum. 

IV.  The    sutures   where    required   are   now   passed 
through  the  flap,  having  already  been  placed  through 
the  old  nasal  borders  and  left  untied.    The  forearm  is 
drawn  against  the  forehead  and  the  arm  is  fixed  in  place 
with  the  retention  apparatus.    The  sutures  are  now  tied. 
They  are  allowed  to  remain  in  about  four  or  five  days, 
not  long  enough  to  irritate. 


RHINOPLASTY 


375 


V.  About    the    tenth    day    the    head    apparatus    is 
removed   and   the   pedicle  of  the   arm  flap   is   divided. 
The  arm  may  now  be  carefully  lowered  to  its  normal 
position. 

VI.  The  subseptum  is  not  formed  from  the  free  end 
of  the  attached  flap  for  several  weeks.    It  is  then  divided 
by  two  parallel  incisions  directed  outward.     The  septal 
section  is  folded  upon  itself,  and  inserted  and  sutured 
in  place  into  an  incision 

made  into  the  upper  lip. 

Szymanowski    Method 

This  author  advises  mak- 
ing the  base  of  the  flap 
sufficiently  wide,  and  of 
the  form  shown  in  Fig. 
350,  to  permit  of  the 
three  sections  of  skin  of 
this  part  of  the  flap  to  be 
folded  upon  themselves 
before  being  sutured  in 
place  at  the  base  of  the 
nose,  so  as  to  form  lined  nares  and  a  thickened  and  sup- 
portative  subseptum. 

Fabrizi  Method. — This  author  utilized  the  immediate 
method  of  flap  fixation,  but  makes  his  flap  of  triangular 
form  from  the  inner  and  upper  skin  of  the  forearm. 

The  transverse  base  is  made  to  lie  one  half  inch  below 
the  radio-ulnar  space.  The  flap  should  be  about  three 
inches  long  and  of  about  the  same  width.  It  is  cut  while 
the  forearm  is  relaxed;  bleeding  is  controlled  by  gentle 
pressure.  In  the  meantime  the  cicatricial  tissue  of  the 
old  nose  margins  has  been  removed  and  the  skin  fresh- 
ened to  receive  the  flap. 

To  approximate  the  parts,  the  hand  is  laid  palm  down 
upon  the  shoulder;  the  resultant  position  of  the  arm  and 
forearm  are  retained  by  bandages.  The  parts  are  now 
sutured.  On  the  thirteenth  day  the  line  of  division  is 


FIG  350. — SZYMANOWSKI  METHOD. 


376     PLASTIC    AND    COSMETIC    SUKGERY 


traced  out  upon  the  arm  with  nitrate  of  silver,  at  the 
same  time  giving  the  flap  somewhat  the  form  required  to 

give   the  nose  its 
contour. 

The  next  day 
the  pedicle  is  cut 
and  the  arm  is 
brought  back  into 
its  normal  posi- 
tion. With  the 
division  of  the 
pedicle  he  advises 
including  a  por- 
tion of  the  apo- 
neurosis  and  a 
•  few  fibers  of  the 
supinator  longus 
muscle. 

The  flap  is  al- 
lowed to  remain 
free  at  its  base 
until  contraction  and  cicatrization  have  been  established, 
when  the  sub  septum  and  wings  are  made. 

The  position  of  the  arm  and  the  attached  flap  at  the 
root  of  the  nose  is  shown  in  Fig.  351. 

He  advises,  when  possible,  to  dissect  up  a  flap  of  the 
cartilage  of  the  old  septum,  letting  it  adhere  at  its  lower 
border  and  turning  it  from  below  upward  with  the  skin 
which  covers  it  to  form  the  subseptum.  This  will  help  to 
hold  up  the  point  of  the  nose  firmly  (an  important  matter 
because  it  is  at  this  point  that  all  noses  constructed  of 
skin  flaps  alone  sink  down  for  the  want  of  suitable  prop 
of  tissue). 

This  cartilaginous  flap  he  held  in  place  with  two  pins 
thrust  through  the  latter  and  the  skin  flap  proper,  and 
held  them  in  place  with  a  figure  twist  of  silk.  He  re- 
moved the  needles  about  the  sixth  day. 


FIG.  351. — FABRIZI  METHOD. 


RHINOPLASTY 


377 


Steinthal  Method. — This  authority  made  the  flap  for  the 
nose    from    the    skin 
over  the  sternum,  pro- 
ceeding as  follows : 

"  From  the  ster- 
num I  cut  a  flap  of 
skin  and  periosteum 
in  the  form  of  a 
tongue  whose  lower 
base  was  five  centi- 
meters wide,  and  the 
summit  forming  the 
pedicle  three  centi- 
meters wide;  its 
length  was  twelve 
centimeters. 

"I  could  have 
taken  away  with  this 
flap  some  of  the  costal 


FIG.  352. 

cartilage  to  utilize 
in  making  the  wings 
of  the  new  nose. 

"  I  dissected  up 
this  flap  and  closed 
the  wound  over  the 
sternum  with  su- 
tures. The  flap  was 
then  stitched  to  the 
forearm  by  its  base 
into  an  incision  of 
appropriate  length 
made  near  the  radi- 
us. (See  Fig.  352.) 


FIG.  353. 
STEINTHAL  METHOD. 


378      PLASTIC    AND    COSMETIC    SUBGEEY 

The  arm  was  properly  fastened  in  a  plaster  apparatus 
and  the  flap  enveloped  in  a  dressing  of  borated  vaselin. 
The  forearm  was  held  in  front  of  the  breast,  an  attitude 
easily  retained.  Twelve  days  later  I  cut  the  pedicle. 

"  I  let  a  few  days  pass  by,  and  then  stitched  the  pedi- 
cle end  of  the  flap  to  the  root  of  the  nose.  A  new  plaster 
apparatus  was  put  in  a  suitable  position.  The  hand  was 
placed  on  the  forehead. 

"  Ten  days  after,  I  detached  the  flap  from  the  arm  and 
reformed  the  nose  with  the  flap,  which  hung  down  like 
an  apron.  It  is  necessary  to  have  a  flap  sufficiently  long 
to  fold  in  for  the  nostrils.  I  used  bronze  aluminum  wires 
for  all  the  sutures." 

The  position  of  the  hand  while  the  flap  was  healing 
to  the  root  of  the  old  nose  and  the  slight  twist  of  the 
flap  is  shown  in  Fig.  353. 

THE  COMBINED  FLAP  METHOD 

To  overcome  the  consequent  cicatricial  contraction  and 
f  ailing  in  of  the  flap  used  to  make  the  new  nose  by  either 
of  the  three  grand  methods  given,  various  surgeons  have 
resorted  to  lining  the  flap  with  skin  flaps,  bringing  their 
raw  surfaces  together  so  that  the  nose  actually  received 
in  this  way  an  integumentary  lining. 

While  this  had  the  tendency  to  thicken  the  new  nose, 
it  did  not  give  the  support  necessary  to  it,  especially  at 
the  lower  third,  and  the  lobule,  at  first  quite  satisfactory, 
resulted  only  in  the  appearance  and  form  of  a  small 
tubercule  of  tissue,  with  a  decided  saddle  effect  above  it. 
This  combined  method  did  overcome,  however,  the  slow 
process  of  cicatrization,  and  its  accompanying  suppu- 
ration. 

The  raw  surfaces  of  the  two  flaps,  if  properly  brought 
together,  healed  upon  themselves  readily,  as  has  been 
referred  to  in  the  lining  or  doubling  in  of  the  basal  sec- 
tions to  form  the  nostrils  and  subseptum. 


BHINOPLASTY 


379 


The  method  of  lining  the  nasal  flap  in  this  manner  is 
never  sufficient  to  give  a  satisfactory  result  in  total  rhino- 
plastic  cases,  but  may  be  of  great  service  in  restoring 
parts  of  the  nose,  as  will  be  shown  later. 

The  requirement  is  that  of  support,  whether  it  be 
organic  or  inorganic,  and  these  methods  will  be  consid- 
ered presently. 

Volkmann  Method. — This  surgeon  fashioned  the  frontal 
flap  as  shown  in  Fig.  354.  This  resulted  in  leaving  a  tri- 
angle of  skin  at  the  root  of  the  nose,  which  he  dissected 


FIG.  354. 


FIG.  355. 


VOLKMANN  METHOD. 


up,  down,  to  and  inclusive  of  the  periosteum,  and  turned 
downward  so  that  its  raw  surface  faced  upward,  as  in 
Fig.  355.  The  flap  was  sutured  into  place  to  retain  it. 

The  frontal  flap  was  brought  down,  so  that  the  two 
raw  surfaces  came  together. 

This  method  overcame  the  contraction  of  the  flap  over 
the  nasal  bridge  or  superior  third  of  the  new  nose,  and 
an  excellent  adhesion  of  that  part  of  the  flap  to  the  de- 
nuded bone  and  flap  resulted,  but  the  same  faults  about 
the  base  were  not  mitigated. 


380      PLASTIC    AND    COSMETIC    SUBGEKY 


Keegan  Method. — The  frontal  flap  method  of  Keegan  has 
been  referred  to.    For  the  lining  of  the  upper  nose  he  cuts 

two  flaps  from  the  skin 
above  the  old  nasal  ori- 
fice, as  shown  in  Fig. 
356,  which  he  turns 
down,  raw  surfaces  out. 
This  gave  a  lining  to 
either  side  of  the  median 
line;  the  skin  remaining 
intact  between  the  two 
flaps  gave  additional 
prominence  and  support 
to  the  upper  third  of  the 
new  nose. 

Verneuil  Method. — Con- 
trariwise to  the  methods 
just  given,  Verneuil, 
after  cutting  out  the 

FIG.  356.-KEEGAN  METHOD.  frontal  flap,  cuts  the  flap 

from  the  remaining  sides 

of  the  old  nose  somewhat  involving  the  skin  of  the  cheeks, 
as  in  Fig.  357.     This  done,  the  frontal  flap  is  simply 


FIG.  357. 


VERNEUIL  METHOD. 


FIG.  358. 


RHINOPLASTY 


381 


turned  down,  raw  surface  out,  and  the  cheek  flaps  are 
slid  over  it,  bringing  the  raw  surfaces  together.  The  in- 
ner borders  of  the  flaps  were  sutured  in  the  median  line, 
as  shown  in  Fig.  358.  The  base  of  the  nose  is  made  from 
the  frontal  flap  by  any  of  the  methods  already  given. 

Thiersch  Method. — The  frontal  flap  is  cut  from  the  skin 
of  the  forehead  in  the  shape  shown  in  Fig.  359.  Then 
two  quadrilateral  flaps  are  raised  from  the  cheeks,  as  also 
illustrated.  These  are  made  wide  enough  that,  when  they 


FIG.  359. 


THIERSCH  METHOD. 


FIG.  360. 


were  brought  together,  their  inner  borders  could  be  made 
to  face  each  other.  In  this  position  they  were  sutured 
along  the  median  line,  so  as  to  give  a  double-gun-barrel 
form  to  the  nose,  with  a  septal  wall  between. 

From  the  lower  border  the  nostrils  were  formed,  giv- 
ing to  the  new  nose^a  normal  appearance,  the  continuous 
septum  curving  downward  to  form  the  subseptum,  the 
whole  being  sutured  to  the  remains  of  the  old  nose. 

The  frontal  flap  was  now  brought  down  over  it,  the 
raw  surfaces  facing  each  other,  and  sutured  in  place,  as 
shown  in  Fig.  360.  Later,  Thiersch  replanted  the  sides 
of  the  nose,  to  give  it  better  contour,  and  attained  a  very 


382     PLASTIC   AND   COSMETIC    SURGERY 


satisfactory  result.  The  frontal  wound  was  covered  with 
skin  grafts,  but  the  cheek  wounds  were  allowed  to  heal 
by  granulation.  The  cicatrization  of  the  latter  was  not 
sufficient  to  effect  the  lower  eyelids  nor  the  angles  of  the 
mouth. 

Helferich  Method. — His  is  an  ingenious  application  of 
the  French  method.  Both  flaps  are  cut  from  the  cheeks ; 
the  lining  flap  was  made  from  the  left  and  the  covering 
one  from  the  right  cheek.  The  shape  of  the  flaps  is 
shown  in  Fig.  361. 

The  lining  flap  is  stitched  along  the  freshened  margin 
of  the  right  side  of  the  nose.  The  flap  should  be  wide 
enough  to  give  convexity  to  the  nose,  as  shown  in  Fig.  362. 


FIG.  361. 


FIG.  362. 


HELFERICH  METHOD. 


The  covering  or  right  flap,  cut  much  larger,  is  now 
slid  over  this.  It  should  be  cut  amply  large  to  cover  the 
flap  just  sutured  in  place.  It  is  sutured  on  both  sides 
of  the  nose  to  hold  it  in  place,  also  at  the  inferior  margin. 
The  nose  is  lightly  packed  with  iodoform  gauze. 

The  pedicle  of  the  right  flap  was  cut  after  two  and 
a  half  weeks  and  brought  into  place  across  the  root  of 
the  nose,  and  sutured  in  place  to  give  better  contour  to 
the  part  after  freshening  the  skin  about  the  left  side  of 
the  nose  at  this  point.  He  does  not  make  a  subseptum, 
but  thinks  the  inferior  base  of  the  nose  of  sufficient  size 
to  hide  the  absence  thereof. 


383 


The  subseptum  could,  however,  be  readily  made  from 
the  upper  lip,  as  will  be  shown  later. 

Sedillot  Method. — This  operation  is  particularly  effica- 
cious in  giving  a  splendid  subseptum  and  support  of  the 
point  of  the  nose,  but  does  not  overcome  the  falling-in  of 
the  whole  anterior  line,  so  common  with  all  Indian-flap 
methods.  A  flap  one  centimeter  wide  and  extending 


FIG.  363. — Anterior  view.  FIG.  364.- 

SEDILLOT  METHOD. 


-Side  view. 


downward  almost  to  the  vermilion  border  is  cut  from 
the  thickness  of  the  upper  lip,  not  including  the  mucous 
membrane,  however.  It  is  turned  upward,  as  shown  in 
Fig.  363. 

The  frontal  flap  is  fashioned  as  shown,  care  being 
taken  to  cut  a  subseptal  rectangle  of  greater  length  than 
usual,  since  it  is  intended  to  overlie  the  raw  surface  of 
the  flap  taken  from  the  lip.  It  is  rotated  downward  and 
sutured  into  place  at  both  sides,  and  also  to  the  lip  flap, 
to  assure  of  accurate  union. 


384      PLASTIC   AND    COSMETIC    SURGERY 

A  lateral  view  of  the  nose  as  formed  in  this  manner 
is  shown  in  Fig.  364. 

The  free  end  of  the  septal  flap  is  fixed  into  the  supe- 
rior lobial  wound  with  a  harelip  pin.  The  lobial  wound 
is  sutured  as  in  ordinary  harelip  operations.  This  method 
is  particularly  valuable  in  total  rhinoplasties  involving 
the  columna  and  alse  in  conjunction  with  flaps  obtained 
by  the  Italian  method. 

Kiister-Israel  Method. — A  flap  was  taken  from  the  arm  by 
the  Italian  method,  which  was  sutured  to  the  remains  of 
the  old  nose  so  that  its  raw  surface  looked  upward,  not 
downward,  as  in  the  ordinary  case. 

The  flap  was  made  sufficiently  large  to  permit  of 
building  the  wings  and  subseptum.  After  it  had  healed 
into  place  the  pedicle  was  cut,  and  a  frontal  flap  was  cut 
from  the  forehead  to  cover  it. 

An  unusually  large  flap  was  required  to  do  this,  since 
it  had  to  overcome  the  greater  curvature  already  given 
and  added  to  by  the  arm  flap,  necessitating  an  extensive 
secondary  wound. 

The  reverse  order  of  procedure  would  be  the  more 
advisable  for  this  reason,  and  is  resorted  to  by  the  fol- 
lowing : 

Berger  Method. — This  surgeon  makes  the  lining  flap 
from  the  forehead.  The  secondary  wound  is  at  once 
closed.  A  flap  is  then  made  from  the  arm  by  the  Italian 
method,  and  brought  into  place  before  the  one  just  made. 
It  should  be  of  sufficient  size  to  allow  of  building  the  base 
of  the  nose,  which  is  done  not  later  than  three  weeks 
after  the  pedicle  of  the  arm  flap  is  severed,  which  may  be 
done  at  any  time  between  the  eighth  and  the  twelfth  day. 

All  the  precautions  are  used  as  already  given  in  the 
description  of  the  Italian  method.  The  arm  is  held  in 
the  position  shown  in  Fig.  365. 

Berger  sutures  the  arm  wound  before  bringing  the 
flap  into  place  upon  the  face  to  overcome  the  discomfort 
of  suppuration  to  the  patient. 


EHINOPLASTY 


385 


The  apparatus  is  fixed  definitely  after  the  patient  has 
recovered  from  the  anesthetic.  Great  care  is  exercised  to 
prevent  coryza  from 
exposure.  Dress- 
ings are  made  twice 
daily. 

The  pedicle  is  cut 
under  local  cocain  an- 
esthesia. 

To  make  the  sub- 
septum  and  wings  of 
the  nose,  the  base  of 
the  flap  is  cut  into 
three  sections.  The 
posterior  surface  is 
freshened  and  the 


FIG.  365. — BEHGER  METHOD. 


themselves    and    sutured 
into  position. 

Instead  of  employing 
rubber  tubes,  he  resorts 
to  a  specially  devised  ap- 
paratus to  retain  two 
metal  tubes  in  the  nares, 
and  at  the  same  time  make 
gentle  pressure  to  the 
sides  of  the  nose  to  miti- 
gate the  columna  contrac- 
tion. The  latter  is  planted 
into  a  V-shaped  incision 

made  into  the  tissue  of  the  upper  lip  at  the  proper 
place  of  attachment.    The  subseptum  may  be  lined  with 

26 


FIG.  366. — BERGER  RETENTION 
'  APPARATUS. 


386     PLASTIC    AND    COSMETIC    SURGERY 

a  flap  of  mucosa  dissected  up  from  the  floor  of  the  inner 
nose. 

For  the  wings  of  the  nose,  such  tissue  as  may  be  of 
service  to  give  them  stability  and  structure  is  taken  from 
the  remains  of  the  old  nose. 

The  apparatus  just  mentioned  and  shown  in  Fig.  366 
is  used  from  the  very  first  day  until  total  cicatrization 
has  taken  place,  and  even  for  a  longer  period  to  aid  in 
shaping  the  entire  nose  and  the  tendency  to  collapse  has 
been  overcome. 

Szymanowski  Method. — A  frontal  flap,  divided  along  the 
median  line  and  shaped  as  outlined  in  Fig.  367,  is  made 
from  the  forehead. 

Two  triangular  flaps  are  then  raised  from  either  side, 
and  including  the  angle  of  the  nose  as  shown.  The  di- 


FIG.  367. — First  Step. 


FIG.  368. — Disposition  of  frontal  flaps. 


SZYMANOWSKI  METHOD. 


vided  frontal  flap  is  now  brought  down  in  such  manner 
that  their  raw  surfaces  meet,  thus  forming  a  vertical 
septum.  The  margins  are  united  by  suture,  and  the  lower 


RHINOPLASTY  387 

ends  are  fixed  into  a  wound  made  for  the  purpose  at  the 
base  of  the  nose,  as  shown  in  Fig.  368,  to  form  the  new 
subseptum. 

The  lateral  triangular  flaps  are  dissected  up  so  that 
they  can  be  readily  slid  forward  toward  the  median  line. 
(Their  inner  freshened  margins  are  sutured  to  the  raw 
edge  of  the  septum  just  made,  and  to  themselves.  The 
objection  here  is  that  there  is  a  liability  of  considerable 
contraction  of  these  lateral  flaps,  with  a  tendency  to  fall 
in  and  drag  with  them  the  new  septum;  and  again,  in 
total  restorations,  the  upper  third  of  the  nose  is  only 
partially  covered,  and  necessitates  later  upbuilding.  The 
author  finds  difficulty  in  making  the  four  margins  thus 
brought  together  unite  evenly  throughout,  and  that  a 
vertical  contraction  is  caused  by  the  cicatrization  of  the 
median  marginal  wound. 

Goris  Method. — The  operation  is  performed  as  follows, 
having  given  very  good  results,  according  to  the  author : 

I.  The  frontal  flap  is  divided  lengthwise  so  that  its 
raw  surfaces  face  each  other.    The  resulting  fold,  repre- 
senting the  bridge  of  the  nose,  is  held  in  place  by  catgut 
suture. 

II.  The  skin  to  make  the  wings  of  the  nose  is  folded 
in,  as  in  the  Langenbeck  method. 

III.  A  flap,  half  the  thickness  of  the  upper  lip  is 
brought  up  to  form  the  new  subseptum. 

IV.  Dissection  and  turning  down  the  triangular  flap 
of  skin  which  surmounts  the  orifices  of  the  old  nose,  and 
making  it  serve  to  line  the  lower  part  of  the  frontal  flap. 

V.  Suturing  the  frontal  flap  thus  modeled  into  two 
grooves  made  into  the  margins  of  the  old  nose  along  both 
sides  to  its  base. 


ORGANIC  SUPPORT  OF  NASAL  FLAPS 

It  soon  became  evident  to  the  rhinoplastic  surgeon 
that  without  some  support  to  the  flap  or  flaps  used  for 


388     PLASTIC    AND    COSMETIC    SURGERY 

the  construction  of  the  new  nose  all  of  the  preceding 
methods,  as  far  as  aesthetic  results  were  concerned:  were 
useless.  Truly,  the  deformity  lost  its  hideous  appear- 
ance to  a  great  extent,  but  the  general  results  obtained 
hardly  warranted  a  patient  to  undergo  restorative  opera- 
tions of  the  nose.  In  fact,  many  surgeons  advised  against 
total  rhinoplasty  when  practically  all  of  the  old  nose 
was  lost. 

Langenbeck  says  "  that  total  rhinoplasty,  or  even 
operation  as  to  repair  partial  loss  of  the  nose  by  the 
use  of  soft  flaps,  should  not  be  undertaken.  It  is  better 
to  rely  upon  some  prothesis." 

All  that  could  be  expected  of  utilizing  the  flap  and 
making  it  heal  into  place  had  been  accomplished  up  to 
about  the  year  1879.  Thereafter  many  surgeons  pro- 
ceeded to  evolve  and  use  some  kind  of  intranasal  prothe- 
sis made  of  various  inorganic  materials.  It  may  be 
stated,  however,  that  Rousset  in  1828  wrote :  "  Perhaps 
some  day  surgeons  will  give  whatever  shape  they  desire 
to  the  reconstructed  nose.  Then  a  frame  of  gold  or 
silver,  cleverly  shaped  and  solidly  fixed  in  the  nose,  will 
give  the  patient,  at  his  own  option,  a  Roman  or  Cartha- 
ginian nose,  and  to  the  ladies  a  choice  of  a  roguish  type, 
and  to  our  Sultans  a  nose  a  la  Roxelane." 

But  it  was  after  1878  that  such  prothesis  came  into 
use,  and  these  were  at  first  made  so  that  they  might  be 
removed  at  night  and  be  replaced  in  the  morning. 

The  intranasal  supports  were  made  of  all  kinds  of 
material,  such  as  gutta  percha,  gold  plates,  leaden  de- 
vices, amber,  silver,  porcelain,  celluloid,  aluminum,  plat- 
inum, etc. 

With  all  due  respect  to  the  ingenuity  of  these  inven- 
tions, especially  that  of  Martin,  which  was  made  of  plat- 
inum in  the  form  of  a  St.  Andrew's  cross,  having  at  the 
four  ends  sharp  pins  which  were  driven  and  fixed  into 
the  skeleton  of  the  nose,  the  use  of  these  protheses  re- 
sulted in  nothing  but  failure. 


K111XOPLASTY  389 

The  movable  devices  were  a  source  of  irritation  and 
pressure,  and  could  not  overcome  the  consequent  con- 
traction of  the  flaps  whether  placed  below  a  single  flap 
or  between  two  flaps,  and  the  fixed  protheses  of  what- 
ever form  or  material  caused  so  much  pressure  that  gan- 
grene resulted,  and  they  had  to  be  removed  sooner  or 
later. 

Before  the  discovery  of  Gersuny,  the  author  had  many 
occasions  to  utilize  such  movable  protheses  in  the  correc- 
tion of  saddle  noses.  These  were  generally  made  of  a 
silver  shell,  gutta  percha,  and  later  of  decalcified  bone, 
as  advised  by  Senn.  The  former  remained  in  place  from 
six  months  to  two  and  a  half  years,  and  then  were  thrown 
off  or  had  to  be  removed  because  of  irritation.  The  bone 
chips  soon  became  absorbed,  leaving  the  nose  as  before, 
or  a  thin  median  strip  that  became  broken  with  the  least 
violence,  and  then  was  absorbed. 

In  several  cases  where  other  surgeons  had  resorted 
to  such  protheses,  the  author  was  called  upon  at  a  later 
period  to  remove  them. 

While  the  immediate  result  is  very  gratifying,  the 
ultimate  result  is  worse  than  useless,  since  in  the  elim- 
ination of  the  foreign  body  the  flap  of  the  nose  was 
married  by  cicatrices  that  added  still  further  to  the  con- 
traction and  falling-in  of  the  nose. 

PERIOSTITIC  SUPPORTS 

Some  other  method  had  to  be  devised,  and  organic 
supports  became  known.  These  organic  protheses  were 
made  of  the  tissue  in  the  near  vicinity  of  the  flap,  and 
at  first  formed  a  part  thereof.  The  earlier  method 
included  only  the  periosteum;  later  bone  and  peri- 
osteum were  added  to  the  flap  to  give  it  shape  and  sup- 
port, and  lastly  cartilage  was  employed  for  the  pur- 
pose. 

Of  the  methods  employing  only  the  periosteum,  it  may 


be  said  that  what  the  surgeon  expected  of  this  mem- 
brane— namely,  the  springing  up  of  bone  cells — did  not 
take  place ;  at  least,  not  to  the  extent  desired.  The  very 
best  to  be  attained  was  a  thickening  of  flap  in  the  mem- 
brane, but  not  sufficient  to  add  necessary  support  to  the 
nose. 

OSTEOPEEIOSTITIC    SUPPORTS 

The  inclusion  of  the  periosteum-lined  flap  was  soon 
abandoned,  and  recourse  was  had  to  such  bone  additions 
to  the  flaps  as  could  be  obtained  from  the  vicinity  of 
the  nose. 

The  bone  was  removed  with  its  periosteum,  adherent 
or  nonadherent  to  the  flap,  as  will  be  shown  by  the 
methods  described  hereafter. 

Both  single  and  combined  flap  methods  are  employed 
as  might  be  expected,  following  the  procedures  of  the 
Indian,  French,  or  Italian  schools.  The  greatest  credit 
for  the  methods  herein  involved  belongs  to  the  surgeons 
of  Germany. 

The  earliest  operation  on  these  lines  was  that  of 
Konig,  who  published  his  first  successes  in  1886. 

Konig  Method, — Extending  upward  from  the  root  of  the 
old  nose,  a  flap  is  outlined  in  vertical  ending  at  the  hair 
line  of  the  scalp,  as  shown  in  Fig.  369. 

This  flap  was  made  about  one  centimeter  wide,  and 
is  made  to  include  the  skin  and  periosteum.  With  the 
chisel  a  thin  strip  of  bone  is  raised  from  the  frontal  bone 
to  nearly  the  full  length  and  width  of  the  flap,  making 
it  an  osteoperiostitic  cutaneous  section  attached  by  its 
pedicle  at  the  root  of  the  nose. 

This  flap  is  brought  down  with  bony  surface  outward, 
and  the  distal  or  skin  end  is  fixed  by  suture  into  the 
upper  lip  at  the  point  of  the  intersection  of  the  sub- 
septum. 

Any  of  the  soft  parts  of  the  old  nose  remaining  are 
now  dissected  up  toward  the  median  line,  and  are  folded 


391 


upward  and  inward  and  sutured  by  their  freshened  mar- 
gins to  this  median  flap. 

An  Indian  flap  in  oblique  direction  and  of  the  form 
shown  is  cut  from  the  skin  of  the  forehead  and  rotated 
down  into  position  before  the  bone-lined  flap,  and  sutured 
into  place. 

He  advises  not  to  in- 
clude the  periosteum  in 
the  flap  making  up  the 
subseptum,  as  it  is  likely 
to  interfere  with  respi- 
ration. In  fact,  he 
deems  it  best  to  make 
the  tegumentary  flap 
sufficiently  long  to  build 
the  bone  of  the  nose, 
doubling  the  raw  edges 
upon  themselves  with  a 
celluloid  tube  apparatus 
that  may  be  removed  for 
cleansing,  and  be  kept  in 


place  long  enough  to 
give  contour  to  the 
nares. 

Von  Hacker  Method. — The  frontal  flap  was  cut  in  the 
ordinary  Indian  method,  and  of  the  shape  shown  in  Fig. 
355.  The  skin  at  either  side  of  the  median  line  was  dis- 
sected up  to  within  four  millimeters,  leaving  a  strip  eight 
millimeters  wide  from  the  root  of  the  nose  to  the  distal 
or  scalp  end.  The  two  loose  lips  of  the  flap  were  brought 
together  at  the  anterior  median  line  by  a  few  sutures  to 
keep  them  in  place. 

This  was  done  to  give  freedom  to  the  surgeon  while 
he  detached  a  strip  made  of  the  periosteum  and  bone 
chiseled  from  the  frontal  bone.  At  the  root  of  the  nose 
or  below  the  pedicle  the  bone  was  not  included  to  the 
extent  that  it  would  interfere  with  torsion  of  the  flap, 


FIG.  369. — KONIG  METHOD. 


I 

1 


392 


RHINOPLASTY  393 

and  yet  sufficient  to  allow  the  raw  bone  surface  to  fall 
upon  what  remained  of  the  bony  bridge  of  the  old 
nose. 

He  utilizes  pins  driven  into  the  bone  to  outline  this 
bony  section,  as  shown  in  Fig.  370. 

The  latter  is  done  in  an  oblique  direction.  See  Fig. 
371.  The  septal  section  is  made  to  include  the  bone  strip. 

The  bridge  of  bone  holding  the  flap  at  its  inferior 
end  was  now  broken,  leaving,  however,  the  periosteum 
as  part  of  the  pedicle  hinge. 

The  whole  flap  thus  outlined  was  rotated  downward 
into  position  and  sutured,  as  shown  in  Fig.  372. 

The  margins  at  the  base  intended  to  form  the  sub- 
septum  were  sutured  behind  the  osseous  structure,  or, 
in  other  words,  were  doubled  inward  and  fixed  by  suture. 
The  bony  strip  was  broken  at  the  proper  point  to  give 
prominence  to  the  lobule. 

The  margins  for  the  nostrils  were  turned  inward  and 
doubled  on  themselves,  and  sutured  with  silk. 

Eubber  tubes  were  left  in  the  nares,  for  drainage  and 
to  keep  them  distended. 

Rotter  Method. — The  frontal  flap  is  made  in  the  shape 
shown  in  Fig.  373,  containing  a  section  of  the  frontal 
bone  and  its  periosteum.  The  width  of  the  flap  is  about 
three  and  a  half  centimeters  wide. 

This  flap  is  turned  downward  so  that  its  raw  surfaces 
look  outward. 

Owing  to  the  loose  adherence  of  the  bony  section  to 
the  skin  flap,  he  allows  the  raw  bone  surface  to  granulate 
over  for  four  weeks,  to  fix  it  more  solidly  to  the  soft 
parts. 

The  bone  plate  is  then  sawn  into  three  sections  made 
by  two  vertical  incisions,  made  as  shown  in  the  illus- 
tration. 

The  median  section  forms  the  bridge  and  dorsal  prom- 
inence of  the  nose. 

The  adherent  skin  of  the  lateral  bony  plates  is  dis- 


394     PLASTIC    AND    COSMETIC    SURGERY 

sected  up  sufficiently  to  permit  of  the  proper  formation 
of  the  sides  and  wings  of  the  nose. 

This  gives  a  shape  to  the  nose,  as  shown  in  Fig.  374. 

The  lateral  margins  of  the  integumentary  flap  are 
now  sutured  to  the  freshened  margins  of  the  old  nose, 


FIG.  373.— First  step. 


FIG.  374. — Disposition  of  frontal  flap. 


ROTTER  METHOD. 


and  the  remaining  skin,  if  any,  is  made  to  cover  the 
granulating  surface ;  if  this  is  lacking  or  insufficient,  skin 
grafts  are  utilized  to  cover  it  completely. 

Schimmelbusch  Method. — The  principle  herein  is  to  give 
an  osseous  wall  to  the  whole  length  of  the  restored  nose, 
covering  well  the  skin  inside  and  outside,  and,  if  possible, 
to  fix  the  new  nose  solidly  at  the  pyriform  opening. 

"  I  cut  an  osteo-cutaneous  flap  from  the  middle  of  the 
forehead,  of  a  size  proportional  to  the  size  and  shape 
of  the  nose.  Its  pedicle  between  the  eyebrows  is  two  or 
three  centimeters  wide;  it  widens  out  superiorly  to  form 
seven  to  nine  centimeters.  It  is  triangular,  and  its  base 
lies  near  the  hair  line.  In  cutting  it  out,  preferably  a 


RHINOPLASTY 


395 


little  large,  it  goes  at  first  to  the  bone,  through  skin  and 
periosteum.  With  a  large,  sharp  chisel,  a  thin  bone  plate 
throughout  the  whole  extent  of  the  cutaneous  flap  is  de- 


\ 


FIG.  375.— First  step. 


FIG.  376. — Disposition  of  frontal  and  skin-grafted  flap. 

SCHIMMELBUSCH   METHOD. 


396     PLASTIC    AND    COSMETIC    SUBGEHY 

tached.  It  is  not  always  possible  to  make  this  a  plate 
in  one  piece;  it  often  breaks  or  gives  off  splinters.  This 
is  of  no  consequence,  if  care  be  taken  not  to  lose  them 
and  to  keep  them  adherent  to  the  periosteum.  They  are 
attached  as  well  as  possible  to  the  cutaneoperiostitic  flap 
by  passing  threads  crosswise  from  one  edge  of  the  flap 
to  the  other  over  bony  surface,  as  in  Fig.  375.  The  whole 
flap  is  then  enveloped  in  iodoformed  suture. 

"  The  frontal  wound  I  close  at  the  same  sitting  by 
sliding  large  lateral  flaps  whose  upper  border  follows  the 
margin  of  the  hair  as  far  as  the  ears.  These  are  freed 
completely,  brought  down  and  stitched,  leaving  eventu- 
ally only  a  linear  cicatrix  on  the  forehead.  The  lateral 
loss  of  substance  which  results  is  healed  by  granulation, 
and  the  scars  concealed  by  the  hair. 

"  At  first  parts  of  the  bone  die ;  they  ought  to  be  ex- 
pected to  fall  out;  after  four,  six,  or  eight  weeks  the 
bone  is  completely  covered  with  fleshy  granulation,  and 
adheres  solidly  to  the  flap.  The  prominent  granulations 
are  then  scratched,  or,  better,  trimmed  away  with  the 
knife,  and  the  whole  surface  is  covered  with  Thiersch 
grafts. 

"  When  the  flap  is  thus  furnished  with  skin  within  and 
without,  it  is  put  into  place.  I  saw  the  bony  plate  with 
a  fine-toothed  saw  from  the  grafted  side;  then  I  model 
the  flap  and  place  it  on  the  loss  of  substance  freshened 
by  turning  the  grafted  surface  toward  the  interior  of  the 
nose  by  twisting  its  pedicle,  as  in  Fig.  376.  The  osseous 
rim  of  the  pyriform  opening  is  uncovered  at  the  moment 
of  this  freshening,  and  the  bony  edges  of  the  flap  are 
placed  exactly  on  the  bony  edge  of  the  aperture.  The 
skin  of  the  flap  is  then  stitched  at  its  lower  margins  to 
the  skin  of  the  cheeks.  To  preserve  the  height  of  the 
nasal  profile  and  avoid  displacing  the  bones  of  the  nose, 
the  nose  is  kept  in  place  with  a  pin  thrust  through  the 
nose,  and  furnished  at  each  end  with  a  rubber  button. 
This  aids  to  form  the  wings  of  the  nose.  If  a  subseptum 


RHINOPLASTY 


397 


is  needed,  it  is  made  by  taking  from  the  skin  that  covers 
the  circumference  of  the  pyriform  opening  two  small 
flaps,  which  are  dissected  from  without  toward  the  me- 
dian line  as  far  as  the  point  where  the  septum  is  nor- 
mally found. 

"  These  are  stitched  at  this  point,  first  upon  them- 
selves, then  to  the  end  of  the  nose.  Three  weeks  later 
the  pedicle  of  the  frontal  flap  is  cut ;  it  is  turned,  put  in 
splints,  and  the  stitching  is  finished." 

Helferich  Method. — A  lining  flap  is  made,  according  to 
the  French  method,  from  the  one  cheek,  which  is  dis- 
sected up  and  turned  over  to  bridge  most  of  the  loss  of 


FIG.  377. 


FIG.  378. 


HELFERICH  METHOD. 


nasal  tissue,  and  sutured  to  the  opposite  freshened  mar- 
gin, as  showed  in  Fig.  377. 

A  frontal  flap,  as  outlined  in  the  same  illustration,  is 
now  cut  from  the  forehead,  leaving  a  pedicle  as  shown, 
and  containing  a  section  of  bone  at  its  median  line.  This 
is  rotated  downward  and  into  place,  and  sutured  along 
the  same  margin  to  which  the  genian  flap  is  fixed,  as 
shown  in  Fig.  378. 

When  the  frontal  and  genian  flaps  have  become  well 
united,  the  latter's  pedicle  is  cut  when  the  freshened  lat- 
eral margin  of  the  frontal  flap  is  sutured  into  place. 


A  suhseptum  is  now  made  or  deemed  necessary  by 
this  surgeon. 

At  a  later  period  the  pedicle  of  the  frontal  flap  is  cut, 
and  fixed  by  suture  and  some  cutting,  to  reduce  the  re- 
sultant prominence  thereof. 

Preidesberger  Method. — This  author  cuts  away  the  skin 
surrounding  the  arch  of  the  old  nose,  and  turns  this 
flap  downward  to  form  the  lining  to  the  flap  made 
from  the  forehead  made  in  the  same  manner  as  Hel- 
ferich. 

The  bone  section  is  made  in  the  median  line,  and  is 
one  centimeter  wide  and  four  long. 

The  frontal  flap  should  be  made  long  enough  to  per- 
mit of  building  a  subseptum  and  the  nostrils. 

Krause  Method. — This  frontal  cutaneo-osteo-periostitic 
flap  is  made  according  to  the  method  of  Konig. 

After  turning  down  the  flap  it  was  covered  with  a 
nonpedunculated  skin  flap  taken  from  the  upper  part  of 
the  arm  by  transplanting  after  its  subcutaneous  fatty 
tissue  had  been  removed.  (See  Fig.  379.) 

This  method  necessitates  a  long-continued  dressing 
of  the  forehead  before  the  pedicle  is  cut,  because  of  the 
needed  nutrition  to  make  the  two  flaps  heal  upon  each 
other. 

After  union  has  been  established  the  sides  of  the 
transplanted  flaps  are  raised  by  dissection,  as  shown  in 
Fig.  380,  to  expose  the  bone  plate  of  the  frontal  flap. 
A  median  strip  is  left  intact. 

With  a  fine  saw  the  bony  plate  is  cut  into  three  sec- 
tions, making  the  narrowest  the  median. 

The  margins  of  the  old  nose  are  now  freshened,  and 
the  combined  flap  is  sutured  along  the  sides,  preserving 
what  tissue  the  surgeon  can  use  to  add  support  to  the 
nose,  which  is  done  by  dissection  and  turning  or  folding, 
as  heretofore  described. 

The  lower  or  forehead  flap  is  sutured  to  the  soft  parts 
of  the  old  nose,  and  the  transplanted  lateral  margins  to 


RHINOPLASTY 


390 


the  marginal  skin  of  the  cheeks,  giving:  to  the  nose  the 
appearance  as  shown  in  Fig.  381. 


FIG.  379. — First  step. 


FIG.  380. — Second  step. 


FIG.  381. — Third  step. 
KRAUSE  METHOD. 


At  a  later  period  the  pedicle  is  cut  and  the  wound  that 
cannot,  at  this  time,  be  overcome  by  sliding  of  the  adja- 
cent skin,  is  covered  by  skin  grafting. 


400     PLASTIC   AND    COSMETIC    SURGERY 


Nelaton  Method. — A  lateral  flap  of  skin  is  taken  from  the 
cheeks,  beginning  on  a  line  with  the  root  of  the  nose  and 
as  low  as  a  point  two  thirds  of  its  normal  length.  These 

flaps  are  made  wide 
enough,  so  that  when  dis- 
sected up  and  folded  in- 
ward they  will  meet  on 
the  median  line,  as  shown 
in  Fig.  382,  having  their 
raw  surface  facing  out- 
ward. They  are  sutured 
along  the  median  line. 
The  frontal  flap  was  cut 
FIG.  382.— First  step.  in  the  form  of  a  horse- 


FIG.  383. — Making  bony  support  to  flap. 
NELATON  METHOD. 

shoe  having  its  pedicle  at  the  root  of  the  nose  just  above 
the  eyebrows,  and  being  about  three  centimeters  wide  and 
six  long. 


EHINOPLASTY 


401 


The    skin   at    the   outer   margins    was    dissected    up 
from  the  bone,  leaving  sufficient  attachment  at  its  cen- 


FIG.  384. — Cutting  through  bony  plate. 


ter  to  allow  for  a  bony 
plate. 

With  a  fine  saw,  and 
in  the  manner  shown  in 
Fig.  383,  this  plate  was 
made  from  the  frontal 
bone,  being  about  two 
and  a  half  centimeters 
wide  and  four  long. 

There  is  some  dif- 
ficulty associated  with 
the  making  of  the  flap, 
which  ends  at  the  supe- 
rior border  of  the  fron- 
tal, leaving  the  pedicle 
composed  only  of  skin. 

The  flap  is  now 
turned  down,  exposing 
its  raw  surface.  The 

27 


FIG.  385. — Disposition  of  frontal  flap. 
NELATON  METHOD. 


402     PLASTIC    AND    COSMETIC    SUEGERY 

bony  plate  is  sawed  through  at  the  median  line,  as  shown 
in  Fig.  384,  and  the  skin  of  the  flap  is  also  divided  along 
this  line,  giving  two  partly  bone-lined  flaps. 

The  two  flaps  are  now  rotated  downward  before  the 
lost  nose,  so  that  their  raw  surfaces  face  inward,  and  in 
this  position  they  are  sutured  along  the  median  line  and 
the  sides,  as  shown  in  Fig.  385. 

The  method  gives  an  angular  dorsum  of  satisfactory 
consistency  to  the  new  nose,  but  furnishes  a  serious  draw- 
back, in  that  the  cicatrization  along  the  median  line  is 
liable  to  affect  the  shape  of  the  organ  and  leaves  a  promi- 
nent scar  line.  The  use  of  two  small  pedicles  is  another 
objection  in  that  the  danger  of  gangrene  is  greater  as  the 
nourishment  to  each  flap  is  less. 

Israel  Method. — From  the  ulnar  side  of  the  left  forearm 
Israel  cuts  a  skin  flap,  as  shown  in  Fig.  386,  with  its 
smaller  end  nearest  to  the  wrist,  where  it  is  detached, 
the  pedicle  being  broad,  assuring  of  better  nourishment 
to  the  flap. 

The  narrow  end  of  the  flap  is  cut  down  to  the  bone, 
then  the  sides  are  dissected  up  until  the  borders  of  the 
ulna  are  reached  on  both  sides,  reserving  an  adherent 
strip  about  eight  millimeters  wide  and  six  centimeters 
long. 


Fio.  386. — ISRAEL  METHOD. 


The  bone  below  this  strip  is  now  removed  with  the 
saw  from  the  lower  end  upward,  and  ending  about  one 
centimeter  beyond  the  base  line  of  the  flap,  where  the 
strip  so  made  is  left  connected  to  the  bone  proper. 


RHINOPLASTY 


403 


The  flap  is  now  raised  gently  and  bent  upward  with- 
out breaking  the  bone.  It  is  sawed  half  through,  trans- 
versely, at  a  point  cor- 
responding to  the  lobule 
of  the  nose. 

The  flap  is  then  en- 
veloped in  iodoform 
gauze,  and  the  head, 
forearm,  and  arm  are 
fixed  in  plaster  of  Paris, 
the  forearm  being  bent 
at  a  right  angle  to  the 
arm  (see  Fig-.  387). 

After  nine  days  the 
osseous  connection  still 
remaining  is  severed, 
and  the  nose  is  modeled 
upon  the  forearm,  as 
heretofore  described  in 
these  operations,  this 
surgeon  using  silver 

wire  to  retain  the  parts.  The  raw  skin  surfaces  are 
allowed  to  heal  upon  each  other  and  the  flap  is  permitted 
to  come  in  contact  with  the  wound  on  the  forearm  tem- 
porarily, to  which  it  might  adhere,  the  gauze  being  now 
removed. 

After  twelve  days  the  newly  modeled  nose  is  freed 
from  such  adhesions  and  kept  from  healing  to  the  parts 
by  using  dressings  between  the  flap  and  wound. 

Five  days  after,  the  margins  of  the  old  nose  are  fresh- 
ened in  the  form  of  an  inverted  V.  If  there  be  sufficient 
cicatricial  tissue  it  is  turned  down,  raw  surface  out,  to 
line  the  new  nose. 

A  prolongation  of  the  pedicle  is  now  cut,  widening  out 
toward  the  radial  side  of  the  arm,  made  obliquely,  as 
shown,  so  that  its  pedicle  now  corresponds  to  a  width  of 
seven  centimeters. 


FIG. 


387.  —  ISBAEL  METHOD.     Position  OP 
forearm  for  placing  of  flap. 


The  whole  flap  except  this  newly  formed  pedicle  is 
cut  free  of  this  forearm.  The  arm  is  put  into  the  posi- 
tion shown  in  Fig.  387,  and  the  freshened  flap  margins  at 
the  root,  the  whole  length  of  the  left  side,  and  part  of  the 
upper  right  lateral.  The  plaster  dressing  to  hold  the 
arm  in  the  proper  position  until  complete  union  is  estab- 
lished is  used.  This  done,  the  pedicle  is  cut,  and  such 
minor  operations  are  done  to  fix  the  remaining  free  mar- 
gin and  the  base  of  the  new  nose. 

CARTILAGINOUS  SUPPORT  or  FLAP 

The  methods  just  described  in  which  an  osseous  plate 
of  various  size  and  form  is  included  with  skin  flaps  for 
the  restoration  of  the  nose  give  undoubtedly  the  best 
rhinoplastic  results.  The  new  nose  is  given  not  only 
better  shape,  but  a  permanency  of  such  form  that  skin 
flaps  of  themselves  could  never  give. 

The  unfortunate  factors  in  these  osteo-cutaneous 
operations  are  the  many  difficulties  experienced. 

The  cutting  or  making  of  the  bony  plate  is  no  simple 
task. 

The  skin  is  an  uncertain  agent  to  employ,  because 
of  the  peculiar  contour  of  the  bony  surface  from  which 
the  plate  is  to  be  removed.  The  chisel,  no  matter  how 
dexterously  used,  is  liable  to  cut  through  the  entire 
bone  thickness,  which  has  occurred  in  several  recorded 
cases. 

There  is  also  the  possibility  of  necrosis  of  a  part  or  all 
of  the  bony  plate  thus  obtained,  and  where  the  latter  is 
not  lined  interiorly  there  is  the  added  danger  of  infec- 
tion. 

Furthermore,  the  secondary  wound  is  more  extensive ; 
the  bone  exposed  requires  about  a  month's  time  to  granu- 
late over  before  skin  grafts  can  be  successfully  applied 
over  it. 

With  the  employment  of  a  cheek-flap  lining  there  is 


KHINOPLASTY  405 

the  added  objection  of  cicatrization.  The  use  of  a  flap 
from  the  arm  is  complicated  and  requires  considerable 
time  for  the  completion  of  the  operation,  and  there  is 
always  the  added  danger  of  infection  and  consequent 
death  of  the  osseous  plate. 

To  overcome  these  many  difficulties  von  Mangold  ad- 
vocates the  use  of  a  section  of  cartilage  to  support  the 
anterior  prominence  of  the  nose. 

It  has  been  found,  since  the  first  attempt  of  and  the 
successful  result  obtained  in  1897  by  this  surgeon,  that 
cartilage  to  be  used  for  this  purpose  should  be  taken 
from  the  costal  cartilage,  where  a  strip  of  the  required 
length  and  width  can  be  obtained. 

The  results  thus  far  recorded  are  excellent,  and  much 
is  hoped  for  from  this  method,  especially  in  the  recon- 
struction of  loss  about  the  wing  of  the  nose  in  partial 
rhinoplasties,  where  the  convexed  contour  may  be  repro- 
duced to  a  nicety. 

The  first  attempt  to  support  the  flap  for  a  total  rhino- 
plasty  by  this  method  was  made  in  1902  by  Charles  Ne- 
laton. 

The  use  of  cartilaginous  supports  may  be  combined 
with  any  of  the  methods  given  heretofore.  The  flap  con- 
taining the  cartilage  may  be  lined  or  unlined.  All  tissue 
found  about  the  old  nose  should,  of  course,  be  utilized  to 
give  added  support  and  to  reduce  as  far  as  possible  ex- 
tensive secondary  cicatrization. 

The  combined  Hindu  and  Italian  methods  give  splen- 
did results,  the  frontal  flap  and  its  support  being  brought 
down  from  the  forehead,  raw  surface  outward,  and  the 
arm  or  forearm  flap  being  placed  immediately  in  front 
of  it. 

The  frontal  flap  with  the  support  requires  a  prelim- 
inary operation  to  permit  of  the  attachment  of  the  carti- 
lage. Fortunately,  this  step  requires  but  little  time  and 
shows  a  very  slight  disfigurement  during  this  period. 

The  secondary  wound  at  the  site  of  the  cartilage  ex- 


cision  requires  little  attention  and  heals  readily,  and  the 
cicatrix  involved  is  very  small. 

Steinthal  proposes  taking  the  flap  and  cartilage  from 
the  thoracic  region,  grafting  it  during  the  preparatory 
period  to  the  forearm,  from  which  it  is  transplanted  to 
the  face  at  a  second  sitting. 

There  is  the  objection  to  this  method  that  it  requires 
the  arm  to  be  retained  hi  position  for  a  very  long  time. 

The  author  advocated  the  use  of  an  arm  flap  made 
by  the  Italian  method  to  line  the  one  to  be  brought  down 
from  the  forehead  in  cases  of  total  rhinoplasty  where 
little  or  no  tissue  can  be  obtained  from  the  remains  of 
the  old  nose.  Such  procedure  reduces  the  time  required 
by  the  Steinthal  method  to  one  half,  and  therefore  greatly 
lessens  the  discomfort  to  the  patient. 

The  fundamental  principles  as  laid  down  by  Nelaton 
are  excellent,  and  may  be  applied  to  any  modification  of 
method  the  surgeon  may  decide  upon  where  a  section  of 
costal  cartilage  is  employed  to  support  the  flap,  whether 
this  be  taken  from  the  forehead,  other  parts  of  the  face, 
or  remote  places. 

The  procedure  of  Nelaton  is  as  follows : 

Nelaton  Method. — The  method  involved  a  preparatory 
and  a  final  operation. 

The  preparatory  operation  has  to  do  with  obtaining 
and  placing  in  position  the  section  of  cartilage  under  the 
skin  flap  wherever  located. 

The  final  operation  may  or  may  not  consist  of  two  sit- 
tings, the  first  being  necessitated  by  the  bringing  upon 
the  remains  of  the  nose  a  flap  of  skin  to  line  the  one 
brought  down  in  front  of  it  and  containing  the  support. 

Preparatory  Operation. — To  begin  properly,  the  fron- 
tal flap  to  be  utilized  is  marked  out  on  the  forehead  with 
nitrate  of  silver  the  day  before  the  operation,  so  that  its 
outline  will  be  plainly  discernible,  and  act  as  a  guide  for 
the  placing  of  the  cartilage.  The  shape  of  the  flap  is 
fashioned  as  shown  in  Fig.  388, 


407 


In  the  illustration  is  also  shown  the  incisions  later 
made  to  utilize  the  borders  of  the  remaining  nose  to  line 
the  frontal  flap.  This  is  done  by  making  an  inverted 
V  incision  at  a  distance  from  the  inner  borders,  corre- 
sponding to  the  lateral  line  of  union  of  the  frontal  flap 
with  the  face.  The  resultant  flap  is  turned  down,  raw 
surface  outward,  curtainlike,  and  is  sutured  to  the  frontal 
flap,  where  it  falls  into  position. 

The  flap  outline  shows  that  its  pedicle  lies  between  the 
outer  end  of  the  inner  third  and  above  the  right  eyebrow 
and  a  little  to  the  left 
of  the  median  line  at 
the  root  of  the  old  nose. 
This  will  avoid  consid- 
erable tension  at  this 
point,  the  rotation  as 
made  being  ninety  de- 
grees. 

Nearly  horizontally, 
as  shown  in  the  figure, 
a  line  is  drawn  through 
the  center  of  the  flap, 
showing  the  position 
the  strip  of  cartilage  is 
to  occupy. 

This  done,  a  pat- 
tern of  the  outline  is 
cut  from  stiff  paper  or 
oiled  silk  to  preserve 

as  a  guide  for  the  making  of  the  flap,  it  being  understood 
that  the  outlining  has  been  made  to  the  measurement  of 
the  required  nose,  allowance  being  given  for  cicatricial 
contraction. 

This  done,  the  surgeon  having  prepared  the  skin 
about  the  costal  prominences  of  the  left  thorax,  he  pro- 
ceeds as  follows: 

A  vertical  line  is  drawn  the  width  of  two  fingers  to  the 


FIG.  388. — NELATON  METHOD. 
frontal  flap. 


Outlining  of 


408      PLASTIC    AND    COSMETIC    SURGERY 

right  of  the  nipple,  as  shown  in  Fig.  389,  the  length  of 
the  line  being  obvious. 

Where  the  vertical  crosses  the  eighth  costal  cartilage 
an  incision  is  made  downward  over  and  not  under  the  bor- 
der of  the  cartilage. 

The  incision  extends  downward  for  a  distance  of  eight 
centimeters,  where  it  is  turned  upward  at  an  angle,  as 
shown,  to  a  distance  of  three  centimeters. 

By  separating  the  muscular  aponeurosis  made  visible 
by  this  incision  the  lower  edge  of  the  eighth  costal  carti- 


FIG.  389. — METHOD  OF  LOCATING  STRIP  OF  CARTILAGE. 

lage  is  exposed.  The  knife  is  moved  along  the  lower  edge 
of  the  cartilage,  dividing  the  fibers  of  the  insertion  of  the 
transverse  muscle  from  without  inward.  The  cartilage 
can  now  be  grasped  between  the  thumb  and  forefinger  and 
be  forced  out  of  its  normal  position  after  a  slight  anterior 
dissection. 

The  union  between  cartilage  and  bone  is  exposed. 
The  chisel  is  used  to  divide  the  cartilage  about  one  centi- 


409 


meter  from  the  rib,  after  the  costal  or  inner  extremity 
has  been  made. 

The  position  of  the  hands  and  the  exposed  cartilage  is 
shown  in  Fig.  390. 

This  accomplished,  the  wound  is  temporarily  dressed. 
The  cartilage  is  then  fashioned  to  suit  the  required  size 
and  shape. 

It  is  thinned  down  on  its  lower  surface  to  about  three 
millimeters  in  diameter.  This  thickness  is  maintained  to 


FIG.  390. — EXCISING  STRIP  OF  COSTAL  CARTILAGE. 

a  length  of  two  and  a  half  centimeters,  the  part  being 
intended  for  the  subseptum. 

A  notch  is  made  on  the  upper  surface  at  this  distance 
from  the  end,  which  marks  the  point  at  which  it  must  be 
eventually  bent  to  form  the  point  of  the  nose.  This  notch 
is  cut  to  two  thirds  of  the  entire  thickness. 

The  required  length,  that  of  the  nasal  line  and  its 
added  septal  length,  is  preserved. 


410      PLASTIC    AND    COSMETIC    SURGERY 


FIG.  391. — CARTILAGE  PLACED 
UNDER  FRONTAL  FLAP. 


The  cartilage  being  prepared  is  now  ready  for  the  in- 
sertion under  the  frontal  periosteum  at  the  site  already 
marked. 

For  this  purpose  a  vertical  incision  one  and  a  half 
centimeters,  extending  down  to  the  bone,  is  made,  as 

shown  in  Fig.  391. 

The  periosteum  is  peeled  away 
from  the  bone  with  the  dull  or 
rounded  handle  of  a  knife. 

The  cartilage  is  now  thrust 
into  the  tunnel  thus  made,  the 
thinned-down,  notched-off  section 
facing  forward  and  lying  toward 
the  vertical  incision. 

The  skin  wound  is  sutured 
and  a  gentle  compress  is  used  to 
keep  the  cartilage  in  contact  with 
the  periosteum,  which  requires  at 
least  two  months.  A  longer  interval  of  time  is  advocated 
to  give  greater  vitality  to  the  cartilage. 

The  wound  of  the  thorax  is  simply  sutured  and 
dressed  as  any  surgical  wound. 

Final  Operation. — The  part  cut  is  prepared  as  in  the 
Hindu  method.  A  lining  for  the  frontal  is  made  of  such 
tissue  as  remains,  and  its  freshened  borders  are  sutured 
where  possible,  as  shown  in  the  last  figure. 

When  this  cannot  be  done,  a  flap  may  be  taken  from 
the  arm,  as  already  suggested,  or  a  Krause  nonpeduncu- 
lated  skin  flap  may  be  used,  according  to  the  methods 
given  heretofore. 

The  epidermis  is  made  to  face  inward.  If  either  of 
these  methods  is  used,  the  frontal  lap  is  not  brought 
down  until  healthy  granulation  has  been  established. 

The  frontal  flap  is  made  to  include  the  periosteum, 
from  which  it  is  separated  with  a  blunt  instrument.  The 
cartilaginous  strip  will  be  found  to  be  attached  to  the 
periosteum, 


KHINOPLASTY  411 

The  freed  flap  is  now  brought  before  the  nasal  defect 
and  fitted  into  place.  The  cartilaginous  strip  should 
occupy  the  anterior  median  line. 

The  subseptal  cartilage  is  bent  inward  and  downward 
and  the  skin  of  the  flap  is  sutured  to  it  with  catgut  to 
form  the  subseptum,  as  shown  in  Fig.  392. 

The  free  margins  of  skin  remaining  at  the  septal  bone 
of  the  flap  are  folded  inward  to  line  the  new  nostrils. 
Catgut  sutures  are  used  to  keep  these  folds  in  position. 


FIG.  392. — BRINGING  DOWN  FRONTAL  FIG.  393. — PLACING  OF  FRONTAL 

FLAP.  FLAP. 


The  nose  is  now  ready  to  be  sutured  into  place.  The 
subseptum  is  inserted  first  and  fixed  into  the  upper  lip, 
then  the  nose  being  held  so  that  its  median  line  occupies 
the  proper  position,  both  wings  are  sutured  to  the  fresh- 
ened margins,  and  lastly  the  sides  (see  Fig.  393). 

The  frontal  wound  may  be  drawn  together  as  near  as 
possible  by  suture. 

Rubber  drainage-tubes  are  kept  in  the  nares  for  a  few 
days,  and  are  thereafter  replaced  by  rolls  of  gauze. 

Dry  dressings  are  preferred  for  the  nasal  wounds, 
which  heal  in  about  five  days. 

A  month  after,  Thiersch  grafts  are  employed  to  cover 
the  frontal  wound  remaining.  They  require  about  eight 
days  to  heal  into  place. 


PARTIAL  RHINOPLASTY 

RESTORATION  OF  BASE  OF  NOSE 

In  this  defect  there  may  be  a  loss  of  the  lobule  and 
both  alae,  including  the  subseptum,  or  there  may  be  a 
lateral  loss,  involving  more  or  less  of  the  base. 

There  are  many  types  of  this  deformity,  so  that  to 
include  all  would  involve  considerable  space,  and  at  best 
most  of  the  operations  involved  would  be  those  utilizing 
the  methods  heretofore  mentioned. 

The  earlier  operations  for  the  correction  of  lesions  of 
large  extent  are  founded  upon  the  use  of  skin  flaps,  which 


Fio.  394. 


FIG.  395. 


STEINHAUSEN  METHOD. 


have  been  shown  to  be  unsatisfactory  because  of  their  con- 
sequent cicatrization.  Reference  is  made,  however,  to  sev- 
eral of  these  to  exhibit  the  disposition  of  the  remaining 
parts  of  the  old  nose. 


RHINOPLASTY 


413 


Later  will  be  considered  the  methods  involving  osteo- 
cartilaginous  supports. 

Steinhausen  Method. — The  inferior  remains  of  the  old 
nose  are  detached  from  the  margins  and  brought  down- 
ward; a  Hindu  flap  is  fashioned  as  shown  in  Fig.  394, 
and  brought  down  to  form  the  new  nose;  the  size  of  the 
flap  is  given  as  being  four  inches  wide  and  eight  inches 
long. 

The  distal  end  of  the  flap  is  sutured  to  the  freed  flaps 
obtained  from  the  borders,  as  shown  in  Fig.  395. 

The  method  is  purely  of  the  Hindu  type,  and  the  re- 
sults are  not,  therefore,  very  satisfactory. 


FIG.  396. 


NEUMANN  METHOD. 


FIG.  397. 


Neumann  Method. — This  author  cuts  down  the  remains 
of  both  lower  margins  of  the  old  nose,  as  in  the  Stein- 
hausen operation.  A  wedge-shaped  section  is  cut  from 
the  entire  thickness  of  the  upper  lid  and  turned  up- 
ward to  form  the  subseptum,  and  is  sutured  to  the 


414     PLASTIC   AND   COSMETIC    SURGERY 

lateral  parts  brought  down  by  the  former  incisions, 
to  which  it  is  sutured  at  the  median  line,  as  shown  in 
Fig.  396. 

Two  lateral  flaps  are  now  made  from  the  sides  of  the 
remaining  nose  retaining  their  cartilages,  as  shown  in  the 
illustration,  A,  B,  C,  D,  showing  one  of  them.  The  two 
flaps  remain  attached,  anteriorly  along  the  median  line 
over  the  bridge  of  the  nose.  These  two  lateral  flaps  A,  B, 
C,  are  turned  down  from  the  point  A,  which  represents 
the  pedicle,  and  are  sutured  at  the  median  line  by  their 
lower  borders,  A,  B,  the  borders  B,  C,  being  thus  brought 
down,  fall  before  the  fresh  borders  taken  from  the  mar- 
gins of  the  old  nose,  to  which  they  are  sutured,  as  shown 
in  Fig.  397. 

This  procedure  will  leave  two  exposed  areas  at  either 
side  of  the  nose,  which  are  permitted  to  heal  by  granu- 
lation. 

Later  Neumann  Method. — An  incision  is  made  to  circum- 
scribe the  remains  of  the  old  nose  at  either  side,  extend- 
ing upward  in  rectangular  form  above  the  root  of  the 
nose,  between  the  inner  canthi  and  upward,  and  some- 
what above  the  eyebrows,  as  shown  in  Fig.  398. 

This  flap  thus  outlined  is  freely  dissected  down  to  the 
bones  of  the  nose,  leaving  it  attached  only  at  the  roots 
of  the  wings,  so  that  it  can  be  turned  downward,  hanging 
over  the  mouth,  like  a  curtain. 

A  deep  transverse  incision  is  then  made  through  the 
remaining  cartilaginous  structure  of  the  nose,  just  below 
the  inferior  borders  of  the  nasal  bones.  This  gives  a 
cartilaginous,  archlike  support  to  this  part  of  the  flap, 
which  is  utilized  to  give  firmness  and  shape  to  the  base 
of  the  new  nose. 

The  incision  just  mentioned  is  depicted  in  Fig.  399,  in 
which  is  also  shown  the  turned-down  flap. 

After  the  hemorrhage  has  been  controlled  the  flap  is 
turned  upward  and  into  such  position  as  to  form  the  new 
nose,  utilizing  the  cartilaginous  arch,  above  referred  to, 


415 


to  the  best  advantage  to  give  the  proper  contour.     This 

will  lower  the  apex  of  the  flap  considerably.    The  lateral 

borders  are  sutured  to 

the  freshened  margins 

where  possible,  but  as 

a  rule  an  opening  is 

left    at    either     side, 

communicating    with 

the  inner  nose,  which 

must    be    healed    by 

granulation. 

The  wound  on  the 
forehead  may  be 
brought  together  com- 
pletely  by  suture.  FIQ.  398. 


FIQ.  399.  FIG.  400. 

LATKR  NEUMANN  METHOD. 

The  appearance  of  the  nose  assumes  at  this  time  the 
form  shown  in  Fig.  400. 


The  objection  to  this  method  lies  in  the  fact  that  the 
cartilaginous  arch  brought  down  with  the  flap  is  usually 
insufficient  to  give  proper  support  to  the  base  of  the 
nose,  permitting  the  lobule  to  contract  and  sink.  In 
most  cases  there  is  an  absence  of  sufficient  cartilage  to 
employ  the  method  at  all.  An  osseous  arch  would,  there- 
fore, preferably  be  incorporated  with  the  flap,  taken 
from  the  remaining  nasal  bones. 

Bardenheuer  Method. — This  author  makes  a  transverse 
incision  across  the  root  of  the  nose,  and  two  lateral  inci- 
sions from  either  end  of  the  first,  carrying  them  down- 
ward and  outward,  as  shown  in  Fig.  401.  These  incisions 
are  made  down  to  the  bone.  With  a  chisel  the  nasal  bones 
are  separated  from  their  frontal  and  superior  maxillary 
attachments,  giving  an  arch  of  bone  to  the  flap,  which  is 
brought  downward  and  outward,  the  bone  being  dissected 
from  the  underlying  mucosa.  To  facilitate  the  bringing 
down  of  this  flap  the  anterior  border  of  the  cartilaginous 
septum  must  be  divided  if  present. 


FIG.  401. — Shape  of  flap.  FIG.  402. — Disposition  of  nasal  flap. 

BABDENHEUER  METHOD. 


The  flap  thus  made  is  attached  only  at  the  two  points 
of  skin  at  the  inferior  borders,  the  epidermal  surface 


417 


looking  inward.  The  archlike  mass  of  bone  is  gently 
bent  backward  at  either  side  to  practically  reverse 
its  convexity.  The  position  of  the  flap  is  shown  in 
Fig.  402. 

The  raw  surface  of  the  flap  above  mentioned  is  now 
covered  with  a  flap  taken  from  the  forehead  in  the  form 
shown  in  the  figures. 

The  resultant  nose  is  entirely  lined  with  skin,  and 
contains  sufficient  bone  to  support  it.  The  objection  is 
that  there  must  necessarily  be  a  large  secondary  wound 
in  the  forehead,  which  must  be  covered  with  Thiersch 
grafts. 

Oilier  Method. — This  author  uses  an  inverted  V  incision, 
beginning  on  the  forehead  at  a  point  about  three  centi- 
meters above  the  superior  margin  of  the  eyebrows.  The 
diverging  incisions  are 
carried  down  to  a  point 
just  above  the  base  of 
what  remains  of  the 
old  nose,  where  it  re- 
mains attached. 

The  shape  of  the 
flap  thus  made  is 
shown  in  Fig.  403. 

The  flap  is  dissect- 
ed up  and  made  to  con- 
tain the  periosteum  as 
far  as  the  juncture  of 
the  frontal  nasal  bones. 

The  skin  over  the 
right  nasal  bone  is  now 
dissected  up,  without, 
however,  including  the 
periosteum.  The  left  nasal  bone,  still  adherent  to  the 
skin,  is  removed  with  the  chisel,  beginning  at  the  median 
line,  then  at  its  frontal  attachment,  and  lastly  along  its 
union  with  the  superior  maxillary  bone. 

28 


Fia.  403. — OLLIER  METHOD.     First  step. 


418      PLASTIC    AND    COSMETIC    SURGERY 


On  the  right  side  what  remained  of  the  cartilaginous 
structure  was  divided  so  as  to  include  it  in  the  flap. 

This  gave  a  large  triangular  flap,  periosteo-cutaneous 
above,  osteo-cutaneous  below  that,  and  ending  in  a  chon- 


FIG.  404. — Second  step.  FIG.  405. — Position  nasal  bone  occupies. 

OLLIER  METHOD. 

dro-cutaneous  border,  attached  to  the  face  by  a  double 
pedicle,  as  shown  in  Fig.  404. 

To  give  further  support  to  this  flap  at  the  median 
line,  Oilier  divided  the  septum  with  the  scissors  in  such 
a  way  as  to  form  an  antero-posterior  cartilaginous  flap 
attached  by  its  lower  base. 

The  flap  was  brought  downward  in  the  same  manner 
as  in  the  method  of  Neumann  and  sutured  into  position, 
the  parts  involved  assuming  the  position  shown  in  Fig. 
405,  in  which  the  lateral  nasal  surface  is  left  uncovered  to 
show  the  space  occasioned  by  the  removal  of  the  nasal 


RHINOPLASTY 


419 


bone,  and  in  dotted  line  the  position  that  bone  now  occu- 
pies. 

In  five  weeks  the  two  nasal  bones  united,  end  to  end, 
and  three  months  after  the  operation  the  space  made  by 
the  removal  of  the  bone  had  become  filled  with  hard  tis- 
sue, that  eventually  ossified  in  about  seven  months. 

Langenbeck  Method. — A  median  incision  is  made  through 
the  remaining  skin  of  the  old  nose,  dividing  it  into 


FIG.  406.— First  step. 


FIG.  407. — Showing  separation  and  ele- 
vation of  nose  Saps. 
LANGENBECK  METHOD. 


halves.  The  incisions  about  the  base  and  the  shape  of 
flap  to  be  brought  down  from  the  forehead  are  shown 
in  Fig.  406. 

The  skin  over  the  nose  is  dissected  up,  moving  toward 
the  cheek,  exposing  the  bony  frame  of  the  nose. 

From  the  lower  border  of  the  pyriform  aperture  two 
elongated  triangular  plates  of  bone  are  made,  being 


420      PLASTIC    AND    COSMETIC    SURGERY 

attached  posteriorly  to  superior  maxillary  bones.  They 
should  be  made  about  one  sixth  inch  wide. 

By  their  subsequent  displacement  they  are  made  to  lie 
antero-posteriorly.  With  a  saw  the  nasal  bones  are  sepa- 
rated from  their  maxillary  connection  from  below  up- 
ward, making  a  median  bone  plate,  which  is  raised  with  a 
levator  to  the  height  desired  for  the  new  nasal  bridge, 
remaining  attached  to  the  frontal  bone,  as  shown  in 
Fig.  407. 

A  frontal  flap  is  taken  from  the  forehead  and  sutured 
to  the  freshened  raw  margins  of  the  lateral  flaps. 

The  bone  plates  are  fastened  to  each  side  of  the  fron- 
tal flap  by  suture. 

The  nasal  base  is  preferably  made  of  the  tissue  re- 
maining of  the  old  nose,  as  depicted,  to  prevent  closure 
of  the  nostrils,  the  only  difficulty  being  to  keep  the 
poorly  nourished  tissue  from  dying.  When  used  the 
raw  surface  is  brought  in  contact  with  that  of  the 
frontal  flap. 

The  objection  in  this  case  is  that  the  median  third 
anterior  line  usually  falls  in  rapidly,  leaving  the  nose 
dished  or  saddled,  and  unless  there  be  sufficient  tissue  to 
construct  the  base,  the  objections  so  often  referred  to 
heretofore  will  occur. 

Ch.  Nelaton  Method. — This  author  uses  an  osteo-cuta- 
neous  flap  taken  from  the  forehead.  The  shape  of  the 
latter  is  shown  in  Fig.  408. 

The  lateral  incisions  are  to  be  made  the  width  of  a 
ringer  from  the  margins  of  the  old  nose,  extending  up- 
ward in  curved  fashion  through  the  inner  edge  of  the 
eyebrows  and  meeting  at  a  point  on  the  forehead,  becom- 
ing slightly  oblique  near  the  border  of  the  hair. 

The  flap  is  dissected  up  from  the  borders  inward,  in- 
cluding the  periosteum,  leaving  a  strip  of  bony  attach- 
ment at  the  median  line. 

The  dissected  sides  of  the  flap  are  held  up  by  an 
assistant  while  the  operator  proceeds  to  chisel  a  thin  bony 


RIIINOPLASTY 


421 


plate  from  the  frontal.    The  bony  plate  ends  just  above 
the  root  of  the  nose. 

The  dissection  is  now  carried  on  downward  until  the 
bones  proper  of  the  nose  appear,  and  latterly,  so  that 
tht  saw  does  not  injure 
the  soft  parts,  and  to 
act  as  a  guide  for  the 
course  of  the  latter. 

The    position    of    the 
flap  and  the  saw  in  po- 
sition is   shown  in 
409. 


Fig. 


FIG.  408. — First  step. 

The  saw  is  made  to 
sever  the  nasal  bones 
from  the  apophyses  of 
the  superior  maxillary. 
The  blade  follows  a  line 
starting  one  centimeter 
anterior  to  the  ante- 
rior and  superior  nasal 
spine,  and  is  directed 
downward  toward  the 
second  molar,  not  going 
entirely  through  the 
apophyses. 

The  latter  are  broken 
with  the  chisel  in  such 

way  that  some  of  the  bony  border  lies  in  contact  with 
the  nasal  process  of  the  superior  maxillary. 


FIG.  409. — Making  lower  nasal  flap  section. 
NELATON  METHOD. 


422      PLASTIC    AND    COSMETIC    SURGERY 


This  fracturing  is  made  as  the  flap  is  still  further 
brought  down,  as  in  Fig.  410. 

The  flap  is  now  so  adjusted  that  its  median  bone-lined 
section  will  form  the  median  third  of  the  nose,  the  base 


FIG.  410. — Forming  base  of  nose. 


FIG.  411. — Ultimate  disposition 

of  entire  flap. 
NELATON  METHOD. 


being  made  by  folding  the  flap  upon  itself,  as  shown  in 
Fig.  411. 

The  raw  surfaces  are  sutured  at  their  point  of  co- 
aptation,  laterally,  and  to  the  margins  of  the  genian 
flaps. 

The  frontal  wound  is  brought  together  by  suture  as 
closely  as  possible,  and  Thiersch  grafts  are  employed  to 
close  any  wound  still  remaining. 

The  objections  to  this  operation  is  that  of  all  bone- 
plate  flaps.  A  flap  containing  a  cartilaginous  support 


EHINOPLASTY  423 

taken  from  the  eighth  costal  cartilage,  as  previously  de- 
scribed, would  undoubtedly  give  the  best  results. 


EESTORATION  OF  LOBULE  AND 

The  defect  being  at  a  distance  from  the  forehead,  the 
employment  of  frontal  flaps  for  the  restoration  of  the 
lobule  and  alae  are  to  be  eliminated;  furthermore,  such 
methods  would  involve  the  incision  and  dissection  of  the 
healthy  skin  of  the  nose  to  no  advantage  but  disfigure- 
ment, and  possible  further  loss  of  the  organ. 

The  results  with  autoplasties  about  this  part  of  the 
nose  are  usually  excellent,  and  particularly  gratifying  are 
those  obtained  with  the  Italian  method,  in  which  the  flap 
is  made  from  the  skin  of  the  forearm. 

French  methods  involving  large  nasogenian  flaps 
are  not  to  be  used  because  of  their  consequent  retraction 
and  cicatrization  of  the  cheeks.  Small  lining  nasogenian 
flaps  may  be  utilized  where  necessary,  since  they  cause 
little  scarring. 

If  the  loss  of  tissue  is  very  small,  the  flaps  to  reform 
the  parts  may  be  taken  from  the  nasal  skin  and  the  sep- 
tum be  made  of  a  flap  from  the  upper  lip.  Both  such 
secondary  wounds  could  be  drawn  together  by  suture, 
leaving  slight  linear  scars.  Operations  of  this  nature 
will  be  described  separately  later.  Some  of  the  methods 
referred  to  might  be  combined  for  small  defects  of  this 
nature. 

Defects  of  larger  extent  may  be  corrected  as  fol- 
lows: 

Kiister  Method. — A  flap  of  considerable  size  is  outlined 
on  the  skin  of  the  arm  and  cut  laterally,  leaving  it  at- 
tached at  both  ends  in  bridge  fashion. 

Gauze  dressings  are  inserted  under  the  flap.  Several 
days  later  the  superior  pedicle  is  severed  and  the  flap  is 
sutured  to  the  freshened  margin  of  the  nose.  An  appli- 
cation of  borated  vaselin  on  gauze  is  used  as  the  dressing. 


424      PLASTIC   AND   COSMETIC    SURGERY 

The  arm  is  held  in  position  by  a  proper  apparatus,  a  plas- 
ter-of-Paris  fixture  being  used  by  the  author. 

Six  days  later  the  brachial  plexus  is  divided  to  half 
its  width,  and  totally  divided  three  days  thereafter. 

Fifteen  days  later  the  free  border  of  the  flap  is  divided 
into  three  sections,  the  median  one  being  made  narrowest. 
The  outer  small  flaps  thus  made  are  sutured  to  the  re- 
maining wings  of  the  nose. 

Five  days  later  the  septum  is  formed  of  the  remaining 
unattached  flap,  which  is  sutured  to  the  stump  of  the  old 
septum.  It  is  not  folded  upon  itself,  but  allowed  to  heal 
by  cicatrization. 

Eight  days  later  minor  operations  are  performed  to 
reduce  the  exuberant  portions  of  the  side  flaps. 

Berger  Method. — This  author  makes  a  flap  of  the  skin 
above  the  border  of  the  nose,  which  he  turns  down,  raw 
surface  outward,  upon  which  he  immediately  brings  a 
flap  from  the  arm.  The  object  of  the  lining  is  to  give 
stability  to  the  base  of  the  new  nose  as  well  as  to 
prevent  curling  and  contraction  of  the  rims  of  the 
nostrils. 

Bayer-Payr  Method. — Two  flaps  two  and  a  half  centime- 
ters wide  are  cut  from  the  nasolabial  furrow,  extending 
down  to  the  lower  border  of  the  inferior  maxillary  bone, 
as  shown  in  Fig.  412. 

The  flaps  are  dissected  up  and  brought  forward  and 
upward,  their  raw  surfaces  meeting  in  the  median  line, 
where  they  are  sutured  upon  one  another  to  the  extent  of 
three  centimeters,  as  shown  in  Fig.  413. 

The  nasolabial  wounds  are  brought  together  by  suture 
except  for  a  small  triangular  space  near  each  pedicle, 
which  are  allowed  to  heal  by  granulation. 

The  superior  borders  of  the  flaps  were  then  united  by 
suture  to  the  freshened  margins  of  the  nose,  which  have 
been  prepared  as  shown  in  the  illustration. 

The  septal  ends  of  the  two  flaps  are  likewise  sutured 
to  the  stump  of  the  old  septum. 


RHINOPLASTY 


425 


The  raw  or  outer  surfaces  of  the  flaps  are  to  be  cov- 
ered with  Thiersch  grafts  when  ready  for  them,  though 
this  may  not  be  neces- 
sary with  small  flaps. 

The  pedicles  of  the 
flaps  are  not  cut  until 
the  end  of  the  fourth 
week,  when  the  fresh 
ends  may  be  sutured  to 
freshened  surfaces  of 
the  wings  made  to  re- 
ceive them. 

The  disposition  of 
the  parts  at  this  period 
is  shown  in  Fig.  414.  FIG.  412.— First  step. 


FIG.  413. — Disposition  of  flaps.  FIG.  414. — Ultimate  placing  of  pedicles 

after  division. 
BAYEK-PAYK  METHOD. 

Ch.  Nelaton  Method. — This  author  in  cases  of  extensive 
destruction  of  the  point  of  the  nose  advocates  the  lining 
of  an  Italian  flap  with  skin  flaps  made  in  similar  manner, 
as  in  the  foregoing  operation. 

The  lining  flaps  are  taken  from  the  nasogenian  fur- 
row, placed  and  sutured  as  just  described,  without  twist- 
ing of  their  pedicles,  and  are  sutured  at  the  median  line 
and  at  their  free  ends  to  the  freshened  septal  stumps. 


426      PLASTIC    AND    COSMHTIC    SURGERY 


The  Italian  flap  is  placed  over  those  two  flaps  imme- 
diately, or  the  Italian  flap  is  first  made  to  unite  to  the 

raw  margin  of  the  defect, 
and  the  two  nasogenian  flaps 
are  made  and  employed  at  a 
later  sitting  by  subplanting. 

The  Italian  flap  may  be 
taken  from  the  arm  or  fore- 
arm, this  surgeon  preferring 
the  forearm.  The  attached 
flap  and  position  of  the  hand 
on  the  forehead  where  it  is 
retained  with  an  apparatus 
for  the  required  time  is 
shown  in  Fig.  415. 

The  adherent  Italian  flap 
and  its  subseptal  addition 
and  the  outlines  for  the  lining 
flaps  are  shown  in  Fig.  416. 

The      secondary      naso- 

Fiu.  415. — Attachment  of  flap  from 

forearm.  geman  wounds   reduced   by 


FIG.  416. — Forearm  flap  in  position 
and  outline  of  lateral  flaps. 


FIG.  417. — Disposition  of  lateral  flaps. 
CH.  NELATON  METHOD. 


suture  and  the  flaps  so  obtained  are  shown  in  Fig.  417. 
The  subseptal  section  of  the  Italian  flap  is  raised  to 


RHINOPLASTY  427 

show  the  disposition  of  the  flap  ends  to  form  the  new 
septum.  The  raised  flap  is  brought  down  and  sutured 
to  the  raw  edges  of  the  two  septal  flaps  covering  the 
median  cicatrix,  its  own  cicatrices  falling  within  the  rim 
of  the  nostrils. 

This  surgeon  advises  in  less  severe  losses  of  tissue  to 
do  without  lining  the  Italian  flap,  but  to  make  the  latter 
large  enough  to  be  able  to  fold  in  enough  of  its  base  sec- 
tions to  line  the  nostrils  to  the  extent  of  the  inferior  line 
of  the  mucosa.  The  flap  should  be  cut  one  fourth  longer 
than  the  nasal  deformity. 

This  procedure  also  overcomes  to  a  great  extent  the 
shrinking  of  the  nasal  orifices. 

The  pedicle  of  the  flap  is  cut  close  to  the  arm  at  the 
end  of  two  weeks.  The  subseptum  may  be  made  at  once 
if  the  flap  shows  good  nutrition,  as  evidenced  by  marked 
bleeding  at  the  time  of  cutting  away  the  bridge  tissue. 

RESTORATION  OF  THE  A.L.M 

The  method  of  restoration  of  the  wing  or  wings  of 
the  nose  depends  largely  upon  the  extent  of  the  tis- 
sue loss. 

The  use  of  the  Hindu  method  is  not  advisable,  since 
the  flap  must  be  made  with  a  long  pedicle,  which  involves 
the  making  of  a  large  wound  and  predisposes  to  conse- 
quent large  cicatrices,  although  many  surgeons  have  re- 
sorted to  the  method.  The  author  does  not  see  any  ad- 
vantage with  this  method,  even  if  the  loss  of  tissue  about 
the  lobule  is  great. 

The  best  results,  both  as  to  the  primary  and  sec- 
ondary wounds,  are  those  obtained  with  the  Italian 
method,  and  in  extensive  cases  the  use  of  a  combined  flap, 
wherein  the  lining  flap  is  taken  from  the  nasolabial  fur- 
row or  just  above  it.  This  leaves  a  linear  scar  that  does 
not  disfigure  the  face,  and  assures  of  better  contour  than 
when  a  single  integumentary  flap  is  employed  which,  as 


FIG.  418. — Making  of  flap. 
Pedicle  anterior. 


FIG.  419. — Disposition  of  flap. 


Fio.  420. — Pedicle  posterior.  FIG.  421. — Disposition  of  flap. 

DENONVILLIER  METHOD, 
428 


EHINOPLASTY 


429 


has  been  so  frequently  mentioned,  is  liable  to  curl  inward 
and  contract  in  an  upward  direction,  adding  little  to  the 
area  of  lost  tissue. 

The  ideal  operations  are  those  which  include  carti- 
laginous supports,  which  may  be  obtained  from  about 
the  border  of  the  deformity  or  from  some  remote  place, 
as  of  the  ear.  The  surgeon  is  hardly  justified  to  use  the 
remaining  healthy  tissue  of  the  nose,  unless  the  case  is 
such  that  the  secondary  wound  can  be  corrected,  so  as  not 
to  add  scars  to  the  face. 

Small  defects  can  be  easily  corrected  by  sliding  flaps 
taken  from  the  vicinity  of  the  defect,  whether  they  in- 


Fio.  422. 


MUTTER  METHOD. 


FIG.  423 


elude  cartilage  or  not,  and  by  granulation  or  dissection 
and  approximation  of  the  skin,  the  secondary  wound  may 
be  entirely  closed.  It  is  remarkable  how  little  linear 


430      PLASTIC   AND    COSMETIC    SURGERY 


scars  show  about  the  nose  when  the  lips  of  the  wounda 
have  been  neatly  brought  together. 

The  author  advocates  the  use  of  the  continuous  silk 
suture  for  this  purpose,  since  it  fulfills  both  the  object 
of  suture  and  splint  and  overcomes  the  corrugating 
effect,  so  often  found  with  interrupted  sutures;  further- 


FIG.  424. 


FIG.  425. 


VON  LANGKNBECK  METHOD. 

more,  a  continuous  suture  is  more  easily  withdrawn,  and 
there  is  no  danger  of  wounding  the  skin  on  removal,  and 
the  discomfort  to  the  patient  is  greatly  reduced. 

From  the  foregoing  descriptions  of  procedure,  the 
surgeon  has  been  sufficiently  familiarized  with  such  steps 

in  rhinoplasty  as  are 
usually  employed,  and 
it  would  be  a  matter 
of  constant  repetition 
to  rehearse  these  same 
steps  for  the  following 
operations;  therefore 
the  author  trusts  the 
illustrations  given  will 
be  sufficiently  lucid  to 


work  from.    All  special 
FIG.  426.-BU8CH  METHOD.  features  to  be  observed 

are  given. 

Denonvillier  Method. — The  secondary  wounds  made  by 
the  two  methods  here  given  may  be  allowed  to  heal  by 


a 
fi 


431 


FIG.  430. 


FIG.  431. 


FIG.  432.  FIG.  433. 

SEDILLOT  METHOD. 

432 


EHINOPLASTY 


433 


granulation  or  be  covered  with  skin  grafts,  as  heretofore 
described. 

Mutter  Method. — A  skin  flap  is  taken  from  the  cheek  and 
slid  forward  into  the  defect  as  shown. 

Von  Langenbeck  Method. — The  skin  flap  is  taken  from  the 
healthy  side  of  the  nose  and  brought  into  the  defect  by 
sliding. 

The  secondary  wound  is  allowed  to  heal  by  granu- 
lation. 

Busch  Method. — The  same  method  as  above  is  employed 
except  that  for  the  incision  A,  C,  which,  upon  dissection 


FIG.  434. 


FIG.  435. 


NELATON  METHOD. 


of  the  skin  in  triangle  A,  B,  C,  allows  the  closure  of  a 
larger  defect  than  could  be  corrected  with  the  lateral 
nasal  flap  alone  (see  Fig.  426). 

The  following  illustrations  are  similar  to  those  given 
and  involve  only  the  skin  in  the  flaps  made,  as  shown. 

29 


434      PLASTIC   AND   COSMETIC   SURGERY 


They  are  only  of  interest  in  portraying  the  position  of 
the  flaps  and  their  pedicles. 


FIG.  436. 


BONNET  METHOD. 


FIG.  437. 


In  the  Bonnet  method  the  flap  is  taken  from  the  entire 
thickness  of  the  upper  lip  and  by  twisting  is  brought  into 
the  defect.  The  pedicle  must  be  cut  at  a  later  sitting. 


FIG.  438. 


WEBER  METHOD. 


FIG.  439. 


Weber  Method. — The  flap  is  made  from  half  the  thick- 
ness of  the  upper  lip,  as  shown  in  Fig.  438,  and  brought 
into  the  defect,  as  in  Fig.  439.  The  pedicle  is  cut  later. 


RHINOPLASTY 


435 


Thompson  Method. — This  author  uses  a  lateral  flap  taken 
from  the  cheek,  as  shown  in  Fig.  441,  and  lines  it  with  a 
flap  of  mucosa  dissected  from  the  septum  antero-poste- 
riorly,  as  shown  in  Fig.  440,  disposing  of  the  latter  flap 


FIG.  440. — Mucosa  flap. 


FIG.  441. 


THOMPSON  METHOD. 


FIG.  442. 


as  shown.  The  raw  surface  meets  the  raw  surface  of  the 
skin  flap,  as  in  Fig.  442. 

At  a  later  sitting  the  two  pedicles  must  be  severed  and 
adjusted  by  small  minor  operations. 

Blandin  Method. — The  flap  is  made  of  the  whole  thick- 
ness of  the  lip.  The  pedicle  is  cut  at  a  second  sitting. 


436      PLASTIC    AND   COSMETIC    SURGERY 


Von  Hacker  Method. — This  author  adds  a  flap  from  the 
nasolabial  region  to  line  that  taken  from  the  healthy  side 


FIG.  443. 


BLANDIN  METHOD. 


FIG.  444. 


of  the  nose,  as  shown  in  the  Langenbeck  method.    There 
is  little  cicatrization  here,  and  the  result  is  excellent  for 


defects  of  large  area. 


FIG.  445.  FIG.  446. 

VON  HACKER  METHOD. 

The  procedure  and  shape  of  flaps  as  used  are  shown 
in  Figs.  445  and  446. 


RHINOPLASTY 


437 


Kolle  Method. — The  author  dissects  away  the  flap  E,  A, 
D  when  part  of  the  mucosa  and  cartilaginous  tissue  re- 
mains, and  where  there  is  a  loss,  total  or  partial,  of  the 
alar  rima,  the  transverse  incision  E  being  made  as  long 


FIG.  447. 


AUTHOR'S  METHOD. 


FIG.  448.. 


as  required  to  overcome  the  defect  by  sliding,  as  in 
Fig.  447. 

The  latter  flap  is  freshened  at  its  inferior  border  along 
the  line  D,  and  a  second  or  bordering  flap  of  sufficient 
width  to  line  and  face  the  nostril  is  taken  up  from  the 
upper  lip,  skin  only,  as  shown  in  area  C. 

The  lateral  or  upper  flap  is  now  slid  down  to  slightly 
overcome  the  loss  of  tissue  and  the  flap  C  is  brought  up- 
ward by  twisting  slightly  on  its  pedicle  and  sutured  in 
place,  as  shown  in  Fig.  448. 

The  secondary  wound  lying  between  the  lines  E  and  £", 
occasioned  by  the  sliding  downward  and  leaving  the  tri- 
angular defect  F,  is  allowed  to  heal  by  granulation.  The 
lateral  flap  is  fixed  along  the  line  A. 

Usually  the  pedicle  of  flap  C  need  not  be  cut,  as  it 
adjusts  itself  under  primary  union. 

The  secondary  lip  wound  is  closed  at  once  by  suture. 


438      PLASTIC   AND   COSMETIC    SURGERY 


The  author  has  also  used  the  inverted  V  incision  of  Dief- 
fenbach,  including  the  cartilage  or  part  thereof  that  re- 
mains above  the  defect,  and  has  moved  this  flap  down- 
ward, suturing  in  Y  fashion  with  good  results. 

Denonvillier  Method. — The  operation  is  similiar  to  that  of 
Dieffenbach  and  the  author's  modification  just  mentioned. 

Its  advantage,  as  in  the  lat- 
ter, is  that  the  inferior  bor- 
der or  nasal  rim  remains 
intact,  and  contains  what 
cartilage  remains  above  the 
defect.  The  shape  of  the 
incision  is  as  shown  in  Fig. 
449. 

The  flap  A,  B,  C  in- 
cludes the  skin  and  such 
cartilage  as  can  be  used, 
while  the  rim  below  the  line 
B,  D  retains  its  lower  cica- 
tricial  border. 

The  flap  is  slid  down 
until  the  defect  has  been 
overcome,  and  the  resultant 
superior  triangular  wound 
is  allowed  to  heal  by  gran- 
ulation. The  dissection  of 
the  flap  is  made  down  to 
the  line  including  the  skin 

or  cartilage  referred  to.  At  the  dotted  line  B,  D  the 
whole  thickness  of  the  tissue  except  the  overlying  skin 
is  involved. 

Von  Hacker  Method. — The  flap  A,  F,  C,  as  shown  in  Fig. 
450,  is  cut  from  the  entire  thickness  of  the  side  of  the  nose 
attached  by  its  posterior  pedicle  C. 

This  flap  is  moved  downward,  and  its  anterior  border 
is  sutured  along  the  freshened  line  A,  B,  as  in  Fig.  451, 
leaving  a  triangular  defect,  A,F,C. 


FIG.  449. — DENONVILLIER  METHOD. 


EHINOPLASTY 


439 


Two  little  triangular  flaps  of  skin  are  dissected  up, 
skin  only,  at  D,  E,  C  and  H,  G,  C. 

Next  a  rectangular  flap,  7,  K,  L,  M,  is  dissected  up 
from  the  cheek,  as  in  Fig.  452,  including  some  areolar 
tissue. 

The  flap  should  be  made  sufficiently  long,  so  that  when 
folded  over  it  will  fit  into  the  defect  without  tension,  at  the 
same  time  allowing  for  contraction. 


^ 


FIG.  450. 


FIG.  451. 
VON  HACKER  METHOD. 


FIG.  452. 


This  flap  is  sutured  into  the  defect  made  by  the  mak- 
ing of  the  first  flap,  as  shown. 

The  secondary  wound  of  the  cheek  is  brought  together 
by  suture,  except  for  a  small  triangle  near  the  pedicle  to 
avoid  its  constriction. 

Its  raw  surface  is  allowed  to  heal  by  granulation. 
The  pedicle  is  severed  in  about  fifteen  days,  and  may  be 
cut  in  triangular  fashion  to  make  it  fit  smoothly  into  the 
slight  defect  in  the  skin  just  posterior  to  it. 

Konig  Method. — In  this  novel  method  a  flap  somewhat 
of  the  form  of  the  defect  is  taken  from  about  the 


440      PLASTIC    AND    COSMETIC    SURGERY 


entire   thickness  of   the  rim   of   the   ear,   as   shown   in 
Fig.  453. 

This  flap  should  be  made  slightly  larger  than  the 
defect,  since  it  contracts  somewhat  immediately  after 

excision. 

It  is  sutured  rim  down 
to  the  freshened  wound  in 
the  wing. 

The  secondary  deform- 
ity of  the  ear  is  brought 
together  by  suture.  The 
author  has  found  that  this 
cannot  be  readily  done 
without  puckering  the  rim 
when  the  line  of  excision 
is  made  convexly,  and  ad- 
vises making  it  triangular 
instead.  The  defect  of  the 
nose  should  be  freshened 
to  the  same  form.  The 

flap  from  the  ear  now  becomes  ideal,  fits  better,  is  more 
readily  sutured  in  place.  No  sutures  should,  however, 
be  made  through  the  apex  of  this  triangular  flap  to 
avoid  gangrene  at  this  frail  point.  Silk  isinglass  at  this 
point  acts  as  a  splint.  Dry  aristol  dressings  are  used. 
Kolle  Method. — When  the  defect  of  the  ala  is  elongated 
and  involves  only  part  of  the  rim,  the  author  has  taken 
a  cutaneo-cartilaginous  flap  from  the  back  of  the  ear. 

The  flap  is  cut  vertically,  and  is  made  to  include  a 
strip  of  cartilage  of  about  the  size  and  form  of  the  defect. 
The  flap  is  immediately  sutured  to  the  freshened  de- 
fect and  folded  upon  itself  with  the  cartilage  facing  the 
inferior  margin  of  the  defect. 

The  flap  thus  employed  exhibits  an  epidermal  face, 
both  inside  and  outside  as  well  as  at  the  rim  of  the 
wing. 

A  case  in  which  this  method  was  used  is  shown  in  the 


FIG.  453. — KONIG  METHOD. 


RHINOPLASTY 


441 


illustrations  454  and  455,  in  which  the  defect  is  shown  in 
the  former  figure,  and  the  result  after  the  sutures  were 
withdrawn  on  the  sixth  day  in  the  latter. 


FIG.  454. 


AUTHOR'S  CASE. 


FIG.  455. 


The  secondary  wound  is  easily  brought  together  by 
suture,  as  the  skin  is  quite  flexible  at  this  point. 


BESTOKATION  OF  NASAL  LOBULE 

This  defect  of  the  nose  has  been  restored  by  the  use 
of  skin  flaps  taken  from  the  forehead,  the  nose  itself,  or 
from  half  or  the  whole  thickness  of  the  upper  lip.  The 
author  does  not  advocate  the  use  of  such  flaps  except 
those  taken  from  the  skin  of  the  inner  side  of  the  fore- 
arm, just  below  the  wrist,  made  according  to  the  Italian 
plan,  as  heretofore  described. 

The  pedicle  of  such  a  flap  is  cut  about  the  twelfth  day, 
and  at  a  later  period,  when  the  inferior  or  free  margin 
has  cicatrized,  the  subseptum  is  formed  and  sutured  to 
the  remaining  stump  or  into  a  wound  in  the  upper  lip 
made  to  receive  it. 

The  skin  of  the  forearm  is  nearer  to  the  thickness  of 


u 


fa 


442 


EHINOPLASTY  443 

the  skin  of  the  nose ;  hence  a  flap  from  it  is  preferable  to 
that  taken  from  the  arm. 

The  method  of  obtaining  the  flap  has  been  fully  de- 
scribed heretofore. 

The  results  obtained  are  excellent  in  most  cases.  The 
resulting  cicatrix  is  barely  visible,  and  may  be  later  im- 
proved by  scar-reducing  methods,  later  described  under 
that  heading. 

The  appearance  of  the  flap  after  the  pedicle  has  been 
severed  and  the  subseptal  section  has  been  put  into  place 
may  be  observed  in  Fig.  456,  and  the  final  appearance 
after  total  contraction,  in  Fig.  457. 

For  very  small  losses  of  tissue  about  the  lobule  non- 
pedunculated  skin  grafts  are  to  be  employed.  The  author 
advises  including  some  of  the  areolar  tissue  with  them  to 
avoid  contraction. 

These  are  to  be  dressed  with  the  blood  method 
referred  to  under  skin  grafting.  Perforated  rubber 
tissue  is  to  be  used  next  to  the  epidermal  surface  to  pre- 
vent the  dressings  from  tearing  away  the  graft  when 
changed. 

Fine  twisted  silk  is  most  suitable  for  suturing  pur- 
poses. The  loops  must  not  be  drawn  too  tightly  and  the 
knot  be  made  so  that  it  rests  upon  the  healthy  skin  of 
the  nose. 

RESTORATION  OF  SUBSEPTUM 

For  the  correction  of  this  defect  various  methods  are 
given,  and  all  of  these  must  be  modified  more  or  less, 
to  meet  the  requirements  or  extent  of  lost  tissue.  In 
some  cases  the  entire  subseptum  is  absent,  while  in  others 
there  is  more  or  less  of  a  stump  remaining.  Again  in 
some,  the  subseptum  required  is  unusually  wide  and  in 
others  quite  narrow. 

While  a  number  of  surgeons  prefer  making  the  flap 
to  restore  it  from  part  or  the  whole  thickness  of  the 
upper  lip,  as  will  be  shown,  the  author  believes  the  best 


444      PLASTIC    AND    COSMETIC    SURGERY 

results  are  to  be  obtained  with  the  Italian  flap  method, 
if  there  be  great  loss  of  tissue,  or  to  attempt  to  restore 
smaller  defects  with  cartilage-supported  nonpedunculat- 
ed  flaps  taken  from  back  of  the  ear,  as  heretofore  de- 
scribed, or  the  cartilage  to  be  used  as  a  support  may 
be  taken  from  the  nasal  septum  itself,  having  its  pedicle 
posteriorly. 

This  strip  of  cartilage  is  brought  downward,  freed 
at  either  side  from  its  mucosal  attachment,  and  the  skin 
flap  to  be  used  is  then  made  wide  enough  to  be  sutured 
to  the  inferior  mucosa  margins  as  well  as  to  the  skin  of 
the  lobule. 

The  method  of  taking  a  sliding  flap  from  the  healthy 
skin  of  the  nose  is  not  advisable,  because  of  the  resultant 
disfigurement. 

The  tissue  of  the  lip,  on  the  other  hand,  can  be  used, 
since  the  secondary  wound  can  be  readily  drawn  to- 
gether, leaving  only  a  linear  scar.  In  men,  this  may  be 
hidden  by  the  mustache. 

"When  the  Italian  method  is  used,  the  method  referred 
to  in  restoration  of  the  lobule  is  to  be  followed. 

Blandin  Method. — The  flap  is  taken  vertically  from  the 
entire  thickness  of  the  upper  lip,  as  shown  in  Fig.  458, 
having  its  pedicle  at  the  base  of  the  nose. 


FIG.  458.  FIG.  459. 

BLANDIN  METHOD. 

This  strip  of  tissue  is  turned  upward,  mucosa  out- 
ward, and  its  freshened  free  end  is  sutured  to  the  raw 
surface  of  the  lobule. 


445 


The  secondary  wound  of  the  lip  is  sutured  as  in  ordi- 
nary harelip,  as  shown  in  Fig.  459. 

The  mucosa  soon  takes  on  the  appearance  of  skin,  but 
in  most  cases  remains  pink  in  color. 

The  flap  taken  in  this  way  should  not  be  made  too 
wide. 


FIG.  460. 


METHOD. 


Fio.  461. 


Dupuytren  Method, — The  flap  is  taken  vertically  from  the 
skin  of  the  upper  lip,  reaching  down  at  -its  free  end  to  the 
vermilion  border,  as  shown  in  Fig. 
460. 

The  flap  is  twisted  upon  its 
pedicle  and  sutured  to  the  skin  of 
the  lobule;  to  facilitate  this  the  left 
incision  is  made  higher  than  that  on 
the  right. 

The  pedicle  may  be  cut  as  with 
all  such  flaps,  and  it  may  be  allowed 
to  remain,  if  not  too  disfiguring. 

The  secondary  wound  of  the  up- 
per lip  is  drawn  together  by  suture, 
as  shown  in  Fig.  461. 

The  mucosa  of  the  nose  is  to  be 
sutured  to  the  raw  edge  of  the  flap  . 

FIG.  462. — SERKE  METHOD. 

when  that  is  possible. 

Serre  Method. — This  author  advises  dissecting  up  a  flap 
from  the  upper  lip,  including  the  skin  only,  leaving  it 
attached  just  above  the  vermilion  border,  as  in  Fig.  462. 


446      PLASTIC   AND   COSMETIC    SURGERY 


The  free  and  upper  end  is  sutured  to  the  lobule. 
When  union  has  taken  place,  the  pedicle  is  divided  and  is 
brought  upward  and  sutured  into  place.  The  secondary 
wound  repaired  by  suturing  finally.  There  is  some  diffi- 
culty in  dressing  the  wound  during  the  time  required  to 
have  it  unite  to  the  skin  of  the  lobule,  because  of  the  dan- 
ger of  pressure  and  consequent  gangrene. 


FIG.  463. 


DlEFFENBACH    METHOD. 


FlQ.    464. 


Dieffenbach  Method. — This  author  took  up  the  skin  flap 
transversely  or  obliquely,  as  shown  in  Fig.  463,  and 
twisted  it  into  position,  as  shown  in  Fig.  464. 

The  objection  to  the  direction  of  making  the  flap  in 
this  manner  is  that  the  consequent  cicatrization  has  a 


FIG.  465. — HEUTEK  METHOD. 


FIG.  466. — SZYMANOWSKI  METHOD. 


tendency  to  draw  the  mouth  out  of  its  normal  position  on 
the  wounded  side. 

The  following  methods  show  the  taking  of  the  flap 


RHINOPLASTY 


447 


from  the  skin  of  the  nose  itself.     Unless  the  defect  be 
very  small  such  methods  are  objectionable. 

Szymanowski  Method. — In  the  latter  method  of  Szyma- 
nowski  the  flap  must  be  stretched  considerably,  to  close 


FIG.  467. 


SZYMANOWSKI  METHOD. 


FIG.  468. 


over  a  lengthy  deformity,  encouraging  gangrene.  The 
deformity  is  not  so  great,  however,  as  with  the  two  pre- 
ceding methods. 

The  author  believes  a  nonpedunculated  flap  with  or 
without  a  cartilaginous  support  should  be  tried  before 
other  methods  are  resorted  to,  in  all  cases,  with  the  hope 
of  healing  the  graft  in  place.  The  fact  that  the  mucosa 
can  in  some  cases  be  sutured  to  the  margins  of  the  flap 
adds  much  to  the  possibility  of  its  subsequent  life  by 
adding  its  nutriment  to  the  graft 


THE  operations  herein  considered  have  to  do  with 
overcoming  deformities,  congenital  or  acquired,  as  a  re- 
sult of  traumatism,  and  in  which  there  is  no  loss  of  tissue, 
the  sole  object  being  to  give  to  the  nasal  organ  a  more 
desirable  size  and  contour. 

There  are  many  types  of  abnormalities  involving 
both  the  size  and  shape  of  the  nose.  Some  of  these  de- 
formities may  be  readily  corrected  by  subcutaneous  or 
submucous  operations,  while  others  involve  more  or  less 
cutting  of  the  skin. 

The  object  of  the  surgeon  at  all  times  is  to  accomplish 
the  best  results  with  as  little  disfigurement  as  possible. 

Anesthesia, — All  the  cosmetic  operations  of  the  nose 
should  be  done  under  local  anesthesia,  unless  there  be 
serious  objections  to  its  employment. 

The  author  advocates  the  use  of  a  four-per-cent  solu- 
tion of  @  Eucain,  in  preference  to  all  others.  It  is 
less  toxic  than  cocain  and  harmless  to  the  patient;  no 
untoward  symptoms  are  exhibited  from  its  use  post-oper- 
atio.  Various  patients  complain  of  slight  uneasiness 
about  the  epigastrium,  and  many  speak  of  a  peculiar 
weakness  about  the  knees,  but  these  symptoms  pass  away 
quickly. 

More  or  less  stinging  is  felt  in  the  wounds  made  in 
this  manner,  immediately  after  the  operations,  especially 
about  the  lobule  of  the  nose,  as  with  blepharoplasties,  but 
this  usually  subsides  in  less  than  an  hour.  It  may  per- 

448 


COSMETIC   RHINOPLASTY  449 

sist,  however,  in  some  cases,  for  several  hours.  It  is  well, 
therefore,  to  acquaint  the  patient  with  this  fact  to  avoid 
worry  or  fear. 

Where  severe,  hot  applications,  dry  or  moist,  may  be 
used  to  overcome  it. 

More  or  less  edema  follows  the  employment  of  local 
anesthetics,  which  passes  away  in  various  lengths  of  time, 
from  one  to  four,  or  even  five  days,  according  to  the 
amount .  used  and  the  site  and  circulation  of  the  part 
operated  upon. 

In  over  ten  thousand  hypodermic  injections  of  eucain 
the  author  has  observed  only  two  cases  of  collapse,  which 
responded  readily  to  the  usual  treatment  employed  in 
such  event,  and  has  never  met  with  a  single  fatality. 

Sutures, — Twisted  silk  sutures  are  to  be  preferred,  as 
they  do  not  invite  sepsis,  as  softening  catgut  does,  and 
retain  the  parts  during  the  entire  time  required  for  heal- 
ing, while  the  latter  is  liable  to  become  separated  by  un- 
even absorption,  allowing  the  wound  to  gape  at  that  point 
and  causing  more  or  less  of  a  cicatrix,  so  intolerant  to 
patients  of  this  class. 

Dressings. — Bulky  bandages  are  not  required ;  they  heat 
the  parts,  and  look  unsightly.  The  author  employs  anti- 
septic adhesive  silk  plaster  for  covering  all  external 
wounds,  except  where  the  hair  prevents  its  use.  Moist 
dressings  are  never  indicated,  except  in  the  later  treat- 
ment of  infected  wounds. 


ANGULAR  NASAL  DEFORMITY 

This  is,  perhaps,  the  most  common  of  all  nose  de- 
formities. The  nose  is  overprominent  about  the  osseous 
bridge,  extending  outward  and  downward,  hook  or  hump 
fashion.  It  may  be  congenital  or  the  result  of  external 
violence. 

There  are  various  methods  of  reducing  the  redundant 
bones  and  cartilage;  those  involving  submucous  excision 

30 


450      PLASTIC    AND    COSMETIC    SURGERY 


are  difficult  to  perform  for  the  inexperienced  operators, 
and  the  external  means  of  reduction  are  advised  to  be  fol- 
lowed. The  resultant  scar,  if  the  skin  has  been  properly 
incised  and  not  damaged  by  retracting  pressure,  and, 
lastly,  properly  and  neatly  sutured,  should  be  barely  vis- 
ible. 

Monk's  Method. — This  author  made  a  small  incision 
through  the  skin  just  posterior  to  the  inferior  edge  of 
the  lobule,  as  in  Fig.  469a.  Then  with  a  dull  instrument, 

introduced  through  the 
opening,  he  detached  the 
connecting  tissue  that 
binds  the  skin  along  the 
anterior  dorsum  as  far 
as  the  root  of  the  nose, 
giving  more  or  less  width 
to  this  freed  area  about 
the  nasal  bones. 

A  dull-pointed  scissors 
is  introduced  through  the 
sublobular  opening,  and 
the  bones  and  cartilage 
are  reduced  until  the  de- 
sired nasal  line  has  been 
attained. 

The  method  of  pro- 
cedure is  shown  in  Fig. 
4696. 

The  wound  is  cleansed 
of  all  spiculae  of  bone  or 
bits  of  cartilage  and  the  skin  opening  is  closed  by  suture. 
Healing  takes  place  with  more  or  less  ecchymosis  in  about 
six  days. 

The  difficulty  the  author  finds  with  this  method  is  that 
it  is  practically  impossible  to  do  good  work  with  the  scis- 
sors in  this  position. 

The  use  of  an  electric  drill  has  been  advocated  to  do 


FIG.  4696. 
MONK'S  METHOD. 


COSMETIC   RIIINOPLASTY 


451 


away  with  the  scissors,  hut  it  is  a  dangerous  instrument 
and  requires  great  skill  for  its  manipulation  and  reduces 
the  hone  particles  to  such  fine  fragments  that  much  of  it 
is  left  in  the  wound,  which  may  induce  sepsis  or  cause 
unevenness  of  the  skin  surface  until  later  absorbed  or 
removed.  The  same  fault  is  observed  with  cartilage, 
which  it  grinds  into  pulpy  pieces  and  for  which  it  should 
never  be  used. 

Anterior    Median    Incision. — This,    perhaps    the    oldest 
method,  has  been  extensively  employed.    The  incision  is 


FIG.  470. 


FIG.  471. 
MEDIAN  NASAL  INCISION. 


FIG.  472. 


made  down  the  median  line  of  the  dorsum  of  the  nose, 
beginning  above  the  deformity,  and  ending  slightly  below 
the  inferior  bone  line,  as  shown  in  Fig.  470.  The  skin  is 
incised  obliquely. 

An  assistant  separates  the  wounds  with  hook  tenaculi, 
exposing  the  osseous  bridge,  as  in  Fig.  471. 

The  author  advocates  dividing  the  periosteum  and 
dissecting  it  well  back  to  either  side  of  the  bony  eleva- 
tion. By  bringing  it  back  over  the  denuded  surface  after 
the  chiseling  has  been  done,  it  aids  materially  in  estab- 
lishing a  smooth  surface  and  hastens  the  bone  repair. 

The  periosteum  being  held  aside,  the  straight  chisel 
and  mallet  are  used  to  reduce  the  bone.  The  operator 
may  proceed  to  do  this  from  above  down  or  vice  versa, 


452      PLASTIC    AND    COSMETIC    SURGERY 


according  to  the  formation  and  position  of  the  protu- 
berance. 

The  redundant  cartilage  is  removed  with  the  knife 
from  above  downward,  cutting  from  side  to  side. 

Usually  the  operator  does  not  remove  enough  of  the 
cartilage  and  a  new  angulation  of  the  nose  appears  after 
the  swelling  has  disappeared,  necessitating  a  second 
operation. 

The  wound  is  closed  as  shown  in  Fig.  472. 

lateral  Incision. — The  incision  in  this  case  is  made 
slightly  posterior  to  the  beginning  of  the  lateral  border, 
as  shown  in  Fig.  473. 

The  skin  is  held  back,  as  shown  in  Fig.  474,  and  the 
same  mode  of  procedure  is  followed  as  that  just  given. 


I 


FIG.  473.  FIG.  474. 

LATERAL  NASAL  INCISION  (Author's  method). 

The  operator  will  have  some  difficulty  to  reach  the 
opposite  anterior  border  of  bone  elevation,  especially  if 
the  incision  has  not  been  made  long  enough.  This  should 
be  done.  At  no  time  should  the  assistant  employ  too 
much  force  in  retracting  the  anterior  flap  to  better  expose 
the  field  of  operation;  it  is  certain  to  cause  gangrene  of 
the  skin. 


COSMETIC    RHINOPLASTY 


453 


To  overcome  a  long  scar  line,  and  to  facilitate  the  cut- 
ting1 away  of  the  bone,  the  author  had  a  special  set  of 
chisels  made  with  curved  cutting  blades,  one  angular 
and  the  other  straight-edged.  There  are  two  each  for 


FIG.  475. 


FIG.  476. 
AUTHOR'S  CHISEL  SET. 

working  from  the  right  and  left  sides.  The  striking 
point  lies  midway  between  the  blade  and  the  end  of  the 
handle. 

They  are  shown  in  Figs.  475  and  476. 

To  the  set  the  author  has  added  a  suitable  metal 
mallet,  an  instrument  very  hard  to  obtain  for  osteoplastic 


FIG.  477. — AUTHOR'S  METAL  MALLET. 


operating.  All  the  mallets  obtainable  are  too  large  and 
heavy  for  delicate  work  (see  Fig.  477). 

After  the  bone  is  reduced  to  the  proper  level,  the 
cartilage  is  cut  away  as  before  described,  and  the  wound 
is  sutured. 

The  resultant  scar  is  much  better  than  when  made  in 
the  median  line,  and  is  not  so  noticeable  in  this  position. 

This  operation  gives  the  best  results  of  all  external 
methods  employed  for  this  purpose, 


454      PLASTIC    AND   COSMETIC    SURGERY 


CORRECTION   OF   ELEVATED   LOBULE 

(Retrousse  Nose) 

This  condition  is  frequently  a  deformity.  The  base 
of  the  nose  is  tilted  upward,  unduly  exposing  the  nares. 

The  author  prefers  to  bring  the  lobule  down  by  exci- 
sion of  the  anterior  third  of  the  subseptum  in  preference 
to  submucous  dissection  of  the  cartilaginous  tissue,  caus- 
ing the  deformity. 

With  an  angular  scissors  introduced  through  the 
nares,  a  triangular  section  of  the  septum  is  removed,  as 
shown  in  Fig.  478.  The  apex  of  the  triangle  should  be 


FIG.  478. 


AUTHOR'S  METHOD. 


FIG.  479. 


placed  well  up  into  the  septum  to  break  the  elasticity  of 
its  structure,  the  base  of  the  triangle  being  sufficiently 
wide  to  somewhat  overcorrect  the  deformity. 

Such  noses  are  usually  narrow  at  the  lobule,  and 
no  interference  with  the  lower  lateral  cartilages  is 
called  for. 


COSMETIC    RIIINOPLASTY  455 

The  septal  mucoid  and  the  subseptal  skin  wounds  are 
brought  together  by  suture,  as  shown  in  Fig.  479,  leaving 
only  a  slight  transverse  linear  scar  on  the  subseptum. 


CORRECTION  OF  BULBOUS  LOBULE 

Roe  corrects  this  deformity  by  making  an  incision, 
either  vertically  or  horizontally,  in  the  mucosa  in  one  or 
both  nares,  through  which  he  introduces  the  blades  of 
a  fine  curved  scissors,  with  which  sufficient  redundant 
tissue  is  removed  to  bring  the  lobule  down  into  the  desired 
contour. 

The  mucosa  should  be  sutured  to  facilitate  rapid  cica- 
trization. The  operation  should  be  overdone  to  get  the 
desired  result. 

Not  infrequently  the  extreme  convexity  of  the  lower 
lateral  cartilage  must  be  overcome  by  either  removal  sub- 
mucously  or  by  excision  of  the  cartilage  itself,  employ- 
ing an  elliptical  incision  in  the  mucosa  for  the  purpose. 

The  alae  are  kept  in  position  after  such  ablation  by 
compress  dressings  or  by  a  suture  made  transversely 
through  both  wings  of  the  nose  and  the  septum,  and  tied 
over  a  quill  or  cork  support  placed  externally  upon  the 
skin  at  either  side  of  the  nose.  This  is  removed  about 
the  sixth  day. 

Sheet  lead  or  a  splint  of  aluminum  of  proper  thickness 
and  covered  with  gauze  may  also  be  used  to  retain  the 
parts  during  cicatrization. 

ANGULAR  EXCISION  TO   CORRECT  LOBULE 

When  the  lobule  is  unduly  broad  at  its  base  and  is 
more  or  less  concave  above  the  rim  of  the  alae,  it  can  be 
reduced  by  removing  a  diamond-shaped  piece  of  tissue 
at  either  side  of  the  subseptum. 

The  bases  of  the  two  triangles  making  up  the  diamond 
at  its  widest  area  meet  at  the  anterior  rim  of  the  nostrils, 


456      PLASTIC    AND    COSMETIC    SURGERY 

extending  with  their  apices  upward  and  backward,  as 
shown  in  Fig.  480. 

If  there  be  a  prominence  of  the  cartilaginous  structure 
of  the  lobule,  this  may  be  removed  subcutaneously  after 
the  two  ablations  have  been  made. 


FIG.  480.  FIG.  481. 

AUTHOR'S  METHOD. 

Before  suturing  the  wounds,  it  is  advisable  to  free  the 
skin  of  the  inferior  lobule  to  overcome  tension. 

The  sutures  are  applied  as  in  Fig.  481.  None  are  used 
to  unite  the  mucosa  unless  the  interior  wounds  are  large 
enough  to  permit  of  their  use. 

CORRECTION   OF  MALFORMATIONS  ABOUT  THE 
NASAL  LOBULE 

The  operations  herein  described  apply  particularly  to 
the  correction  or  reduction  of  an  overprominent  nasal 
tip  due  to  an  excessive  growth  of  congenital  malforma- 
tion of  that  part  of  the  nose,  giving  the  organ  undue 
prominence  and  a  hooklike  appearance,  usually  associ- 
ated with  a  narrow,  sharply  upward  inclined  upper  lip. 

Pozzi  Method. — The  same  operation,  on  a  larger  scale, 
can  be  readily  employed  for  the  correction  of  hyperplasia 
nasi  and  rhinophyma. 

In  the  operation  of  Pozzi  (Bulletin  et  memoir e  de 
Societe  de  chirurgie,  1897,  p.  729)  an  elliptical  section  of 
skin  and  cartilage  are  removed  from  the  lobule  with  its 
widest  part  corresponding  to  the  point  of  the  nose;  the 
cicatrices  occasioned  thereby  are  practically  as  bad,  if 
not  worse,  than  the  unscarred  overprominent  nose,  while 


457 

the  submucous  procedure  of  Eoe  (Medical  Record,  July 
18,  1891)  is  not  only  insufficient  in  these  cases,  but,  ac- 
cording to  my  experience,  practically  useless. 

Eoe  Method. — Roe's  method  requires  a  submucous  ex- 
tirpation of  the  redundant  cartilage  at  the  tip  through  a 
necessarily  small  opening  within  the  nasal  orifice,  also  the 
division  in  several  places  of  the  anterior  fold  of  the 
lower  lateral  cartilage  with  the  object  of  reducing  the 
undue  convexity  of  the  alas.  The  latter  is,  we  might  say, 
impossible,  since  the  cartilages  will  be  reduced  by  such 
a  method,  even  under  pressure  dressings,  which  are  likely 
to  cause  gangrene  of  the  skin  of  the  wings ;  or  if  this  be 
avoided,  the  cicatrix  resulting  from  such  division  usu- 
ally restores  the  very  fault  that  it  is  expected  to  over- 
come, while  the  mucous  lining  of  the  alas  becomes  thick- 
ened and  more  firmly  tied  down  than  previous  to  the 
operation. 

One  is  tempted  to  exsect  the  major  curvature  of  the 
lower  lateral  cartilage,  but  this  leads  to  a  flattening  of 
the  wings  of  the  nose,  partial  atresia  of  the  nasal  orifice, 
and  a  decided  lack  in  its  symmetry. 

Secondly,  in  Eoe's  operation  there  is  always  a  lack 
of  knowing  how  much  or  how  little  to  remove  of  the 
cartilage  of  the  tip,  a  second  cosmetic  operation  being 
made  necessary  after  the  parts  have  contracted  and 
healed,  a  common  fault  with  most  cosmetic  plastic  oper- 
ations performed  under  local  anesthesia,  owing  to  the 
immediate  edematous  enlargement  following  its  hypoder- 
mic use. 

Operation  as  Commonly  Practiced. — The  operation  hereto- 
fore most  commonly  practiced  is  one  in  which  an  ellipti- 
cal piece  of  skin  is  cut  from  the  tip  of  the  nose,  followed 
by  the  extirpation  of  the  anterior  prominences  of  the 
lateral  cartilages,  and  amputation  of  the  septal  carti- 
lages. Unfortunately,  the  result,  at  first  quite  satisfac- 
tory to  the  eye,  culminates  in  the  pulling  apart  of  the 
cicatrix  formed  by  bringing  the  sides  of  the  wound  to- 


458     PLASTIC    AND   COSMETIC    SURGERY 


getlier  along  the  median  line  with  a  later  depression  of 
the  tip  in  this  median  line,  occasioned  by  the  outward 
traction  of  the  lower  lateral  cartilages.  Even  a  second 
or  third  operation  does  not  overcome  this  result  entirely, 
and  at  best  leaves  an  ugly  irregular  gash  in  the  me'dian 
line  of  the  tip  and  the  columna. 

In  one  of  the  cases  here  cited  this  same  operation  had 
been  unsuccessfully  tried  twice  by  another  surgeon,  with 
very  unsatisfactory  and  unsightly  result.  (Case  II.) 

The  ideal  operation  for  all  of  this  type  of  cases  from 
the  view  of  the  surgeon  is  to  leave  as  little  disfigurement 
as  possible,  and  the  method  to  be  here  considered,  when 
properly  followed,  leaves  no  scar  whatever,  except  for 
a  slight  white  line  across  the  columna  of  the  nose,  where 
it  is  out  of  view,  and  when  contracted  offers  no  objection 
on  the  part  of  the  hypercritical  patient. 


FIG.  482. 


AUTHOR'S  METHOD. 


FIG.  483. 


Author's  Method. — The  method  of  the  author  is  as  fol- 
lows: Given  a  nose,  typified  by  the  illustration  in  Fig. 
482,  the  skin  above  the  site  of  the  operation  is  thoroughly 
cleansed  with  soap  and  hot  water,  then  rinsed  with  alco- 
hol, ninety-five  per  cent,  and  vigorously  scrubbed  with 


459 

gauze  sponges,  dipped  into  hot  bichlorid  solution, 
1  to  2,000,  followed  with  a  thorough  lavage  with  sterilized 
water.  Both  nostrils  are  now  cleansed  with  warm  boric- 
acid  solution  by  the  aid  of  small  tufts  of  absorbent  cotton 
wound  over  a  dressing  forceps.  The  patient  is  then  in- 
structed to  breathe  through  the  mouth  during  the  opera- 
tion. A  number  of  small  round  gauze  sponges  dipped 
into  sterilized  water  and  squeezed  dry  are  placed  within 
reach  of  the  assistant.  About  one  drachm  of  two-per- 
cent Beta  Eucain  solution  is  now  injected  about  the  tip 
of  the  nose,  the  columna,  and  the  ake,  as  far  back  as  their 
posterior  fold. 

A  thin  bistoury  is  then  thrust  into  the  nose  from  right 
to  left,  entering  at  the  point  E  (Fig.  483),  and  brought 
down  parallel  to  the  anterior  line  of  the  nose,  and  emerg- 
ing below  the  tip  in  a  line  with  the  anterior  border  of  the 
nasal  orifices.  This  procedure  leaves  a  strip  (.4)  about 
one  quarter  inch  wide,  laterally,  rounded  at  its  inferior 
extremity,  and  attached  superiorly  to  the  nose.  Next  the 
round  inferior  tip  (B)  is  cut  away  obliquely,  sloping  in- 
ward toward  the  nose  by  the  aid  of  a  small  angular 
scissors.  Each  blade  of  the  angular  scissors  is  now 
placed  into  each  nostril,  the  tips  of  the  blades  inclined 
forward,  and  the  columna  or  subseptum  is  divided  at  C, 
also  the  septum  along  the  line  D  up  to  a  point  a  little 
above  the  first  incision  made  externally  at  E.  The  two 
arterioles  of  the  columna  are  controlled  by  the  use  of 
mosquito-bill  forceps.  The  two  projecting  folds  of  the 
lower  lateral  cartilage  in  the  columna  are  next  severed 
as  deeply  as  possible  to  give  mobility  to  the  stump,  a  step 
necessary  to  overcome  the  changed  position,  otherwise 
resulting  in  a  droop,  which  would  have  to  be  corrected 
at  a  later  sitting. 

The  next  step  is  to  give  the  needed  shape  to  both 
wings.  This  is  accomplished  with  a  specially  designed 
scissors,  so  curved  on  the  flat  that  its  convexity  facing 
upward  corresponds  to  the  normal  curvature  of  the  ori- 


460      PLASTIC    AND    COSMETIC    SUEGEEY 

ficial  rim.  A  clean  cut  with  these  scissors,  beginning  at 
G  and  ending  at  the  point  E,  is  made,  leaving  the  base  of 
the  nose,  as  shown  in  Fig.  484.  The  anterior  flap  A  is 
now  bent  backward  to  meet  the  stump  of  the  columna 
at  (7.  If  it  does  not  fall  readily  into  place  a  little  inore  of 

the  septal  cartilage  is  re- 
moved along  the  line  D 
until  this  is  accomplished. 
It  may  be  necessary  to 
shorten  the  flap  A  in  cases 
where  a  very  prominent 
hook  is  to  be  corrected. 


FIG.  484.  FIG.  485. 

BASE  OF  NOSE  AFTER  EXCISIONS. 

The  free  end  of  the  flap  A  is  now  sutured  with  No.  4 
sterilized  twisted  silk  to  the  stump  of  the  columna  at  B. 
Two  stitches  usually  suffice  (see  Fig.  485).  One  or  two 
sutures  may  also  be  taken  across  the  angles  of  union  of 
the  alae  and  the  flap  A.  The  inferior  raw  surface  of 
each  wing  may  be 'found  to  be  too  wide,  owing  to  the 
presence  of  the  thickened  cartilage  at  this  point  of  the 
wing.  The  skin  and  the  mucous  membrane  are  then 
carefully  peeled  away  from  the  cartilage,  and  the  lat- 
ter cut  away  as  high  as  possible,  or  a  gutterlike  in- 
cision is  made  along  its  edges  as  shown  in  C  (Fig. 
485),  excising  the  elongated  elliptical  piece  of  tissue 
which  includes  the  cartilage.  The  raw  mucocutaneous 
edges  of  the  wings  are  now  brought  together  with  a 
No.  1  twisted  silk  continuous  suture,  completing  the 
operation, 


461 

An  antiseptic  powder  is  dusted  over  the  parts  oper- 
ated on,  and  small  gauze  dressings  are  applied  with  the 
aid  of  strips  of  silk  isinglass  plaster.  A  small  tampon 
of  cotton,  well  dusted  over  with  an  antiseptic  powder,  is 
placed  into  each  nostril. 

The  dressings  are  changed  the  second  day,  when  the 
resultant  swelling  will  have  practically  subsided.  The 
sutures  in  the  columna  are  removed  the  fourth  day  pref- 
erably, and  those  of  the  wings  about  the  sixth  day.  Com- 
plete cicatrization  follows  in  about  ten  days,  when  the 
patient  can  be  discharged. 

The  following  cases  are  given  to  show  the  types  of 
cases  thus  far  operated  upon  and  to  illustrate  the  results 
obtained : 

Case  I.- — Mr.  R.,  aged  thirty-two;  foreman  mechanic. 
Had  been  operated  upon  for  angular  nose,  also  at  point 


FIG.  486.  Fia.  487. 

AUTHOR'S  CASE. 

of  nose  by  Dr.  S.  Presented  himself  for  operation  Octo- 
ber 19,  1904,  when  cast  was  made  (see  Fig.  486).  Bro- 
mides given  during  recovery.  Patient  had  been  subject 
to  fits  of  depression  on  account  of  his  nose  for  over  a 


462      PLASTIC    AND    WSMKTIC    SURGERY 

year.  Wounds  healed  in  ten  days,  when  second  cast  was 
made  (Fig.  487).  Complete  recovery. 

Case  II. — Miss  B.  P.,  aged  twenty-two;  actress.  Pa- 
tient presented  herself  for  operation  March  22,  1905.  A 
long,  irregular  depressed  cicatrix  showing  at  point  of 
nose,  the  result  of  an  attempt  to  reduce  tip  of  nose 
by  an  elliptical  extirpation  of  the  lobule  (Dr.  N.).  No 
cast  was  made  of  the  case  at  the  time,  so  that  a  second 
cast  showing  the  result  would  be  of  no  use.  Recov- 
ery complete  in  twelve  days.  Patient  returned  to  her 
profession  three  weeks  later  much  pleased  with  the 
result. 

Case  III. — Mr.  L.  L.,  aged  twenty-eight ;  broker.  Pre- 
sented himself,  at  the  advice  of  Dr.  T.,  for  operation 


FIG.  488.  FIG.  489. 

AUTHOR'S  CASE. 

May  2,  1905.  Cast  of  cast  made  and  shown  in  Fig.  488. 
Uneventful  recovery  in  twelve  days,  when  case  Fig.  489 
was  made. 

Case  IV. — Mr.   M.  B.,   aged  twenty-eight;  operatic 
baritone.    Presented  himself  for  operation  June  4,  1906. 


COSMETIC   RHINOPLASTY 


463 


Photograph  shown  in  Fig.  490.    Uneventful  recovery  in 
fifteen  days,  when  photograph  in  Fig.  491  was  made; 


FIG.  490. 


AUTHOR'S  CASE. 


FIG.  491. 


angular  nose  operated  upon  (at  this  time  discharged;  re- 
covery complete). 

Case  V. — Miss  L.  W.,  aged  twenty-seven.  Presented 
herself  for  operation  and  cast  (Fig.  492)  made  August  4, 
1906.  Uneventful  recovery  in  ten  days.  Cast  of  result 
made  August  18,  1906  (see  Fig.  493). 

In  each  of  these  cases  the  patient  was  discharged 
highly  satisfied  and  well  pleased  with  the  result  of  the 
operation,  although  in  Case  V  the  patient  was  requested 
to  return  in  about  one  month  for  an  operation  to  reduce 
the  width  of  the  wings  of  the  nose,  which  was  not  at- 
tempted at  the  first  sitting,  but  could  have  been  with  little 
difficulty  by  beginning  the  primary  incision  at  E,  Fig.  483, 
higher  up,  and  cutting  out  a  triangular  section  on  either 
side  of  the  flap  A,  the  apex  of  each  triangle  being  at 
point  E,  and  the  base  along  the  line  D.  The  wounds  are 
sutured  along  the  dorsum  of  the  nose  with  No.  1  twisted 


464      PLASTIC    AND    COSMETIC    SURGERY 

silk,  after  exsecting  much  of  the  lower  lateral  cartilages 
of  the  wings,  as  can  easily  be  reached  in  the  triangular 
point  formed  by  the  raw  dorsal  border  and  tLe  inferior 
edge  (F).  The  latter  method,  however,  would  be  likely 
to  leave  a  slight  cicatricial  line  on  either  side  of  the  nose. 
This  could  be  much  overcome  by  making  the  incision  from 


FIG.  492.  FIG.  493. 

AUTHOR'S  CASE. 

point  E  to  B  obliquely  to  the  plane  of  the  skin,  likewise 
the  posterior  sides  of  the  triangles  mentioned,  just  as 
the  incisions  at  B,  and  across  the  columna  at  C,  are  made. 
Recovery  should  be  complete  in  five  days. 

DEFICIENCY   OF  NASAL  LOBULE 

Where  there  is  a  lack  of  lobular  prominence  it  may 
be  enlarged  and  brought  forward  by  a  subcutaneous  pro- 
thesis  if  the  skin  is  flexible  enough  to  permit  of  injection, 
as  has  heretofore  been  described.  If  this  cannot  be  done, 
the  following  operation  may  be  employed  to  advance  the 
point  of  the  nose,  and  reduce  the  width  at  its  base  so 
commonly  observed  with  these  cases. 


COSMETIC   RHTNOPLASTY 


465 


Gensoul  Method, — A  deep  incision  is  made  from  the  floor 
of  each  nostril  downward  and  backward,  meeting  at  a 
point  just  below  the  union  of  the  subseptum  with  the 
upper  lip,  as  in  Fig.  494. 

The  deeper  tissues  are  loosened  from  their  attach- 
ments to  the  bone  until  the  subseptum  at  its  base,  in- 
cluding the  triangular  appendage  thus  made,  is  freely 
movable. 


FIG.  494. 


GENSOUL  METHOD. 


FIG.  495. 


The  lobule  is  now  drawn  forward  to  its  required 
prominence  and  the  parts  are  sutured  Y  fashion,  as  in 
Fig.  495. 

If  the  subseptum  be  too  wide,  an  elliptical  section  is 
removed,  including  the  cartilage,  sufficient  to  give  it  the 
desired  thickness  when  brought  together,  as  illustrated. 
The  lips  of  the  wound  are  brought  together  as  shown. 

CORRECTION   OF  WIDENED  BASE   OF  NOSE 

When  the  base  of  the  nose  at  its  juncture  with  the 
lip  is  too  broad,  the  reversed  procedure  mentioned  under 
correction  of  a  broad  lobule  is  to  be  employed. 

The  diamond-shaped  section  is  removed  from  the  pos- 
terior rim  of  the  nares  as  shown  in  Fig.  496. 


FIQ.  496. 


31 


AUTHOR'S  METHOD. 


FIG.  497. 


466      PLASTIC   AND   COSMETIC    SURGERY 

The  tissues  at  either  side  are  freed  from  their  sub- 
cutaneous attachments  so  as  to  render  them  mobile. 

The  mucosa  and  skin  wounds  are  sutured  as  in  Fig. 
497. 

A  retention  splint  or  suture  is  to  be  employed  to  re- 
tain the  parts  as  with  the  anterior  lobule  operation  just 
described  until  healing  has  taken  place. 


REDUCTION   OF  THICKNESS   OF  AUE 

When  the  alae  are  thickened  they  add  to  the  width 
of  the  nasal  bone  and  cause  more  or  less  atresia  of  the 
nostrils.  The  cause  may  be  due  to  superabundant  con- 
nective tissue  or  a  congenital  enlargement  of  the  lower 
lateral  cartilage. 

To  overcome  this  deformity  the  following  operations 
may  be  followed : 

Linhardt  Method, — This  author  excises  an  elliptical  sec- 
tion of  tissue  from  the  inferior  base  of  both  nasal  wings, 
as  shown  in  Fig.  498. 

A  similar  procedure  has  heretofore  been  described  in 
Fig.  485  in  connection  with  correction  of  the  lobule. 


FIG.  498.  Fro.  499. 

LINHARDT  METHOD. 

The  section  removed  includes  as  much  of  the  cartilage 
as  is  necessary  to  thin  out  the  wing  of  the  nose  and  to 
overcome  the  atresia. 

The  parts  are  sutured  as  shown  in  Fig.  499. 

Dieffenbach  Method. — In  this  method  cone-shaped  sec- 
tion of  skin  and  cartilage  are  removed  from  the  wings  of 
the  nose,  as  shown  in  Fig.  500. 


COSMETIC    RITINOPLASTY  467 

If  the  septum  is  too  wide,  two  or  three  of  the  same 
shaped  sections  are  removed  from  it. 


FIG.  500.  FIG.  501. 

DlEFFENBACH  METHOD. 

The  skin  wounds  are  drawn  together  by  suture,  as 
shown  in  Fig.  501. 


CORRECTION   OF  NASAL  DEVIATION 

In  this  deformity  the  nose  is  bent  or  twisted  to  one 
side.  The  cause  is  usually  traumatism,  but  may  be  con- 
genital. 

The  interior  cartilaginous  septum  is  usually  found 
malformed  on  one  or  both  sides. 

To  correct  the  deviation,  the  redundant  cartilaginous 
septum  is  cut  or  sawed  away  to  clear  both  nares  and 
the  anterior  nasal  vestibule.  After  this  has  been  done 
the  nasal  attachments  are  freed  subcutaneously,  until  the 
nasal  organ  is  freely  movable  from  its  attachment  to 
the  superior  maxillary  bones. 

The  nose  is  now  placed  in  the  position  desired,  some- 
what overdoing  the  correction,  and  is  held  in  place  by 
gauze  packs  in  the  nares  or  by  Roberts'  spear-pointed 
pins  thrust  through  the  lateral  skin  of  the  nose  at  either 
side  and  through  the  septum,  as  shown  in  Fig.  339,  p.  365. 

The  use  of  the  pins  placed  as  shown  allows  of  free 
drainage  to  the  nares  and  gives  little  inconvenience  to 
the  patient. 

Plugs  of  gauze  contract  and  harden,  thus  overcoming 
the  object  of  their  use  and  cause  a  disturbance  of  the 
wounds  and  pain  when  reapplied. 

The  pins  should  not  be  withdrawn  until  the  nose  has 


468      PLASTIC    AND    COSMETIC    SURGERY 

healed  into  its  new  position,  or  begin  to  cause  irritation 
of  the  parts  punctured. 

Where  the  deviation  is  unilateral  it  should  be  cor- 
rected by  subcutaneous  injection,  as  previously  described. 


UNDUE  PROMINENCE    OF    NASAL   PROCESS   OF  THE 
SUPERIOR   MAXILLARY 

The  protuberance  of  bone  lies  external  to  the  middle 
meatus,  involving  an  abnormal  convexity  of  the  nasal 
process  of  the  superior  maxillary.  Its  external  removal 
or  reduction  involves  considerable  tissue  and  would  leave 
a  conspicuous  linear  scar,  therefore  the  surgeon  must 
attempt  its  reduction  from  the  inner  nose. 

The  author  prefers  to  make  a  horizontal  incision 
below  the  inferior  border  of  the  process,  beginning  ante- 
riorly just  before  the  articulation  with  the  nasal  bone 
and  extending  backward  as  far  as  the  view  from  the 
nare  will  allow. 

Through  this  opening,  the  skin  overlying  the  bone  is 
raised  by  dull  dissection.  A  fine  nasal  saw  is  next 
introduced  through  the  submucous  wound  and  several 
vertical  incisions  are  made  into  or  even  through  the 
bone  about  three  sixteenths  of  an  inch  apart,  dividing 
the  convexed  osseous  tissue  into  several  sections  adher- 
ent at  their  superior  extremity  which  lies  inferior  to 
the  insertion  of  the  levator  labii  superioris  alaeque  nasi 
muscle. 

A  forceps,  such  as  Adams's,  is  now  introduced  and 
each  section  of  bone  thus  made  is  fractured  from  below 
upwards  inwardly  to  produce  a  concavity  of  the  osseous 
tissue. 

The  operation  requires  considerable  dexterity.  The 
amplitude  of  the  sawing  movement  is  very  much  re- 
stricted, because  of  the  palpebral  muscular  attachment 
just  above. 

A  frail  bone  cutting  forceps  may  be  employed  and 


COSMETIC   RHINOPLASTY  469 

the  lower  half  of  the  process  be  removed  to  avoid  en- 
croachment upon  the  middle  meatus,  but  this  is  rarely 
necessary,  as  that  chamber  is  found  unusually  wide  in 
this  case.  If  the  bone  is  removed,  the  remaining  bone 
may  be  cut  into  sections,  as  described,  or  by  the  cutting 
forceps,  and  fractured  backwards  as  described. 

Retention  dressings  must  be  resorted  to,  to  keep  the 
fragments  of  the  bone  in  their  new  position  until  cicatriza- 
tion has  been  sufficiently  established  to  keep  them  in 
place. 

When  possible  Roe  advises  sawing  off  the  convexity 
submucously  and,  after  loosening  the  skin  over  the  dor- 
sum  of  the  nose,  to  move  the  bony  plate  thus  made  over 
to  the  opposite  side  of  the  nose  and  into  the  concavity 
usually  found  there  in  these  cases.  If  there  be  no  de- 
viation at  the  latter  site  the  bone  plate  can  be  entirely 
removed  through  the  inferior  wound  in  the  mucosa. 


CHAPTER    XVII 


ELECTROLYSIS  IN  DERMATOLOGY 

SEVERAL  references  have  been  made  in  the  preceding 
chapter  to  the  specific  use  of  electricity  without  a  descrip- 
tion, however,  of  its  source  or  application.  The  author 
does  not  deem  it  necessary  in  this  volume  to  go  into  the 
principles  of  electricity,  and  takes  it  for  granted  that  the 
practitioner  is  sufficiently  familiar  with  a  knowledge  of 
the  rudiments  of  the  subject  and  that  he  understands 
the  meaning  of  an  electric  cell  commonly  known  as  a  bat- 
tery. 

The  Electric  Battery. — An  electric  cell  or  battery  is  made 
up  of  two  poles  which  are  named  positive,  designated  by 

the  +  (plus)  sign,  and  nega- 
tive by  the  —  (minus)  sign. 
In  the  usual  form  of  cell 
used  the  parts  are  made  up 
of  a  carbon  and  zinc  cylin- 
der placed  into  a  glass  jar 
containing  the  electrolyte  or 
actuating  fluid.  The  latter 
is  either  an  aqueous  solution 
of  potassium  bichromate  or 
salammoniac  contained  in  a 
glass  jar. 

For  continuous  use  or 
open  circuit  work  the  Le 
Clanche  type  of  cell  is  most 

FIQ.  502.— ELECTRIC  WET  CELL.  practicable. 

470 


ELECTROLYSIS   IN    DERMATOLOGY  '    471 

In  Fig.  502  a  cell  of  this  type  is  shown  in  which  the 
positive  pole  or  element  is  composed  of  a  solid  piece 
of  carbon  forming  a  cover  to  the  glass  jar  as  well,  and 
the  negative  element  is  of  zinc.  The  covering  over  of 
the  jar  prevents  evaporation  of  the  solution  and  adds 
much  to  its  life. 

The  Voltage  or  Electromotive  Force. — The  voltage  or 
electromotive  force  from  such  a  cell  averages  about  1.5 
volts.  Voltage  represents  the  force  or  propelling  power 
of  current  known  scientifically  as  the  electromotive  force 
and  designated  EMF.  Owing  to  the  great  resistance 
of  the  body  to  the  electric  current,  a  proportionate  force 
is  required  to  attain  therapeutic  results. 

The  unit  measure  of  the  quantity  of  current  is  known 
as  the  ampere.  As  this  is  too  great  for  therapeutic  use, 
the  thousandth  part,  or  milliampere,  is  employed,  and 
for  the  purpose  of  measuring  the  amount  of  current 
given  the  patient  the  milliamperemeter  is  included  in 
the  circuit  or  flow  of  current. 

The  unit  of  resistance  is  termed  the  Ohm,  and  to 
simplify  the  method  of  electrotherapeutic  administration 
the  practitioner  may  refer  to  Ohm's  law  as  a  guide.  He 
must  remember  the  average  resistance  to  the  current 
of  the  parts  to  be  operated  on  by  this  process.  The 
law  is  as  follows: 


C 
or 


Current 

in 
Amperes 


(  EMF  or 
(  Voltage 


m 

or 


Resistance, 
or  commonly  written 
R 


C  = 


EMF 


The  Rheostat. — When  we  consider  that  the  resistance 
between  electrodes  placed  on  the  palm  of  the  left  hand 


472     PLASTIC   AND    COSMETIC    SURGERY 

and  the  back  of  the  neck  is  about  4,000  Ohms,  it  may  be 
readily  understood  that  considerable  voltage  is  required 
to  overcome  this  resistance  before  the  proper  amount  of 
current  can  be  employed.  Since  each  cell,  for  quick  ref- 
erence, may  be  said  to  represent  one  volt,  at  least  twelve 
and  not  more  than  sixteen  cells  would  be  required  for 
electrolysis.  Not  all  of  the  current  given  off  by  a  battery 
of  such  number  of  cells  should  be  used  on  a  patient  for 
electrolytic  purpose.  Some  method  must  be  employed  to 
reduce  this  voltage  and  to  control  it  at  will.  This  is  neces- 
sary since  the  life  of  a  cell  varies  and  its  current  capacity 
is  limited  according  to  the  use  the  cell  is  put  to.  An  in- 
strument of  this  nature  is  called  a  rheostat  and  is  usually 
made  of  graphite  or  metal  wire.  Water  resistances  are 
also  used,  but  they  do  not  permit  of  a  constant  current  be- 
cause of  the  consequent  heating  and  decomposition  of 
the  water  into  its  elements  at  the  two  metal  poles  ex- 
posed to  the  water.  The  proper  instrument  will  be  re- 
ferred to  later. 

The  electric  cell  represents  a  certain  voltage;  to  add 
to  this  more  cells  are  needed  and  connected  with  each 
other  so  that  each  adds  its  voltage  to  other  or  the  circuit. 
The  method  of  connecting  cells  in  this  manner  is  called 
series  connection,  in  which  the  carbon  element  of  one  cell 


e  z  z  z          e. 

Fio.  503. — SERIES  CONNECTION. 

is  connected  with  the  zinc  of  the  next,  and  so  forth, 
until  the  last  cell,  leaving  two  free  poles,  one  carbon  and 
a  zinc  to  which  the  wires  to  hold  the  electrodes  for  the 
patient  are  connected.  As  has  been  said,  the  carbon  is 
the  positive  pole  and  the  zinc  the  negative.  The  method 
of  connection  is  shown  in  Fig.  503. 

These  two  poles  when  brought  in  contact  with  human. 


ELECTROLYSIS    IN    DERMATOLOGY       473 

tissue  exhibit  different  action  and  effect.  Without  going 
into  electro-chemistry  it  may  be  said  the  current  of  the 
positive  pole  is  sedative  and  that  of  the  negative  irritant 
or  destructive.  That  oxygen  and  acids  are  freed  at  the 
positive  pole  and  hydrogen  and  alkalies  at  the  negative 
pole. 

It  is  due  to  these  properties  of  the  current  that  it  is 
employed  therapeutically,  but  to  properly  employ  it  the 
current  must  be  controlled  so  that  the  exact  amount  given 
or  used  can  be  estimated.  This  is  accomplished  first  of 
all  by  the  interposition  of  resistance  within  the  circuit. 
This  resistance  should  be  such  that  the  current  can  be 
increased  or  decreased  at  will.  It  has  been  referred  to 


T'fpa^                          1 
J             wu 

<.   i 

0 

gfl                            —  {$*  —  -^<i>        __ 

r 

•^HEoywr 

FIG.  504. — SHUNT  RHEOSTAT  CONNECTION. 

and  is  called  a  rheostat.    Its  position  in  the  circuit  is 
shown  in  Fig.  504. 

Cell  Selector. — The  physician  may  do  without  such  a 
rheostat  and  use  a  cell  selector  with  the  object  of  adding 
one  or  more  cells  to  the  circuit  at  will.  Such  instrument 
is  composed  of  a  marble  or  wooden  base  with  a  number 
of  disks  upon  it,  each  disk  representing  a  cell  of  the 
battery.  A  metal  arm  is  made  to  slide  over  these  disks, 
and  as  it  advances  over  each  disk  the  current  from  that 
cell  is  added  to  the  circuit.  It  may  have  a  second  arm 
which  is  used  to  cut  out  the  current  from  the  cell  or  cells 
at  the  beginning  of  the  circuit — in  fact,  will  permit  of  the 
selection  of  any  cell  in  the  circuit  by  proper  manipula- 
tion. Such  a  selector  is  shown  in  Fig.  505. 


474      PLASTIC    AND    COSMETIC    SURGERY 

The  connection  of  the  cells  of  the  battery  when  a 
selector  is  used  varies  from  that  just  mentioned.     The 


FIG.  505. — CELL  SELECTOR. 


proper  wiring  with  the  disks  of  the  selector  is  shown  in 
Fig.  506. 


FIG.  506. — CELL  SELECTOR  AND  BATTERY  ARRANGEMENT. 


ELECTROLYSIS    IN    DERMATOLOGY       475 


Milliamperemeter. — The  fact  that  a  proper  resistance 
has  been  forced  in  circuit  is  not  alone  sufficient  to  permit 
of  the  proper  use  of  current  for  electrolysis.  A  meas- 
uring device  should 
be  included,  as  has 
been  referred  to  and 
called  the  Milliam- 
peremeter or  Milliam- 
meter.  It  is  shown 
in  Fig.  507. 

The  method  of  con- 
necting this  instru- 
ment in  series  with  the 
current  from  the  rheo- 
stat has  been  shown 
in  Fig.  509. 

The  Electric  Current. 
— Where  the  operating 
room  of  the  physician 
is  provided  with  street 
current  it  will  be  found 


FlG.    507. MlLLIAMPEREMETER. 


FIG.  508.  —  DIRECT  CURRENT 
SWITCH  BOARD  OR  WALL 
PLATE. 


«!*ei«T- 

UPPUV 


FIG.  509. — WALL-PLATE  CONNECTIONS. 


476      PLASTIC    AND    COSMETIC    SURGERY 

more  economical  and  cleaner  to  use  that  current  for 
this  purpose. 

Usually  the  direct  current  is  furnished  of  a  voltage 
varying  from  100  to  125  volts.  To  utilize  such  a  current 
a  wall  plate  is  employed  and  connected  to  the  circuit, 
as  shown  in  Fig.  508.  The  resistance  of  an  electric  lamp 
is  added  to  guard  against  injuring  the  patient  if  by  any 
accident  or  negligence  the  circuit  has  been  improperly 
closed. 

Whether  the  street  or  battery  current  is  used  with 
such  a  plate  makes  no  difference  except  that  with  a 
battery  circuit  the  lamp  is  not  used.  The  connections 
are  given  in  Fig.  509. 

It  will  be  observed  that  a  current  changing  switch 
has  been  added  to  the  wall  plate.  This  is  included  in 
the  circuit  to  permit  of  changing  the  poles  to  the  patient 
without  interfering  or  disconnecting  the  electrodes  if 
desired  at  any  time  during  treatment. 

Portable  Batteries. — The  above  instruments  and  circuits 
refer  to  those  to  be  used  in  the  operating  room  and  are 


FIG.  510a. — PORTABLE  WET  CELL  DIRECT  CURRENT  APPARATUS. 

stationary.  The  physician  may  be  called  upon  to  treat 
a  patient  at  a  distance  and  for  this  purpose  must  have 
a  portable  battery. 

There  are  many  such  instruments  on  the  market  of 
both  dry  and  moist  cell  type.     The  moist  cells  usually 


ELECTROLYSIS    IN    DERMATOLOGY       477 

require  a  bichromate  of  soda  or  potash  solution  and  are 
so  constructed  that  the  carbon  and  zinc  poles  are  taken 
out  of  the  electrolyte  or  solution  and  placed  into  water- 
tight compartments  provided  for  them.  Such  an  appa- 
ratus is  shown  in  Fig.  510a. 

The  best  cell  for  this  purpose  is  the  silver  chloride 
battery.  It  is  compact,  light  in  weight,  and  gives  a  steady 
current.  The  only  objection  is  the  high  cost. 


FIG.  5106. — DIRECT  CURRENT  DRY  CELL  APPARATUS  WITH  RHEOSTAT 
AND  INTERRUPTED  CURRENT  ATTACHMENT. 


Portable  batteries  should  be  furnished  with  a  milliam- 
peremeter.  A  type  of  a  compact  dry  cell  direct  current 
apparatus  is  shown  in  Fig.  5106.  In  the  end  the  best 
apparatus  proves  the  most  economical. 

Electrodes, — Having  the  circuit  or  current  under  con- 
trol, it  now  becomes  necessary  to  attach  electrodes  to  the 
free  poles  to  be  able  to  properly  apply  it  to  the  patient. 
These  electrodes  vary  considerably  according  to  their 
use.  The  author  will  refer  to  only  those  that  are  of 
service  in  electrolysis. 

Sponge  Electrode. — The  one  electrode  held  by  the 
patient  is  usually  made  of  a  metal  disk  covered  with  felt 


478      PLASTIC    AND    COSMETIC    SURGERY 


or  sponge  attached  to  a  wooden  handle  and  is  shown  in 
Fig.  511. 

This  electrode  represents  the  positive;  the  negative 
pole  is  held  by  the  operator.     When  used,  the  felt  or 


FIG.  511. — SPONGE  ELECTRODE. 


sponge  is  moistened  with  warm  water  to  which  a  little 
salt  has  been  added  and  is  placed  into  the  palm  of  the 
hand,  sponge  inward. 

The  author  prefers  to  use  a  plain  metal  disk  with 
the  sponge  and  places  a  piece  of  absorbent  cotton  or 

gauze  over  it  when  in  use 
for  hygienic  reason. 

When  the  operator  pre- 
fers he  may  resort  to  arm 
or  wrist  electrodes  which 
can  be  clamped  upon  the 
limb  and  be  held  in  position 
and  shown  in  Fig.  512. 

The  hand  electrode  is  of 
greater  service  since  the  pa- 
tient can  regulate  or  make 
and  break  the  current  at 

will,  a  matter  of  no  small  consequence  when  fairly  large 
currents  are  being  used  to  destroy  a  growth  upon  the 
skin  of  the  face. 

Needles  and  Needle  Holders. — For  the  negative  elec- 
trode the  operator  uses  a  needle  holder  with  a  needle 
of  proper  form  and  material. 

Two  needle  holders  are  shown  in  Figs.  513  and  514. 
When  the  operator  desires  he  may  employ  an  inter- 


FIG.  512. — ARM  ELECTRODE. 


479 


rupting  needle  holder  with  which  he  can  make  and  break 
the  current  at  will  during  the  operation.  It  is  shown 
in  Fig.  515. 

Such  a  device  is  not  advocated,  since  the  patient  is 
liable  to  jump  as  the  current  is  made  suddenly,  because 


FIG.  513. 


FIG.  514. 
ELECTROLYTIC  NEEDLE  HOLDERS. 


of  the  sharp  stinging  pain  felt  at  the  point  when  the 
needle  has  entered  the  tissue  or  hair  follicle,  often  result- 


FIQ.  515. — INTERRUPTING  CURRENT  NEEDLE  HOLDER. 

ing  in  the  breaking  of  the  needle  and  possible  injury  to 
the  patient. 

Other  operators   employ  a   small  magnifying  glass 
which  may  be  attached  to  the  holder,  as  in  Fig.  516,  and 


FIG.  516. — NEEDLE  HOLDER  WITH  MAGNIFYING  GLASS. 

by  a  sliding  arrangement  be  moved  up  or  down  the 
handle  to  adjust  the  lens  to  the  proper  focus.  This 
arrangement  is  indeed  novel  and  may  be  of  service  in 
removing  fine  superfluous  hairs,  but  the  author  has  never 
resorted  to  the  method. 


480      PLASTIC   AND    COSMETIC    SUKGERY 

The  proper  kind  of  needle  to  be  used  for  electrolysis 
varies  with  the  device  of  the  operator.  The  ordinary 
cambric  needle  usually  advocated  is  too  stiff  and  thick. 
Jeweler's  broaches  are  better,  but  are  very  brittle  and 
easily  broken.  The  ideal  needle  should  be  very  thin  and 
made  of  platinum  or  irido-platinum.  The  author  pre- 
fers the  sharp  to  the  bulbous-pointed.  For  the  removal 
of  other  blemishes  than  hair  from  the  face  the  sharp 
needle  only  can  be  used. 

REMOVAL   OF   SUPERFLUOUS   HAIR 

The  moistened  sponge  electrode  connected  to  the  (  +  ) 
positive  pole  of  the  circuit  is  placed  into  the  hand  of 
the  patient,  who  lies  in  a  chair  with  her  head  on  a  level 
with  the  physician's  chin  when  operating.  The  light 
should  be  southern,  or  such  that  the  shafts  of  the  hairs 
show  plainly. 

The  operator  turns  on  the  current,  holding  the  needle 
holder  in  the  right  hand  which  is  connected  by  a  flexible 
cord  to  the  (  — )  negative  pole.  The  rheostat  handle  is 
brought  back  so  that  just  the  least  current  is  flowing. 
The  needle  is  now  thrust  down  into  the  follicle  contain- 
ing the  hair.  This  must  be  done  very  gently  so  as  to 
feel  when  the  papilla  has  been  reached  by  the  needle. 
The  depth  to  which  the  needle  goes  varies  very  much 
according  to  the  size  and  place  of  the  hair.  It  may  be 
less  than  one  eighth  and  more  than  one  fourth  inch. 

The  patient  holding  the  sponge  will  at  once  feel  a 
stinging  sensation  when  the  needle  enters  the  skin,  which 
is  later  not  as  objectionable.  The  current  is  now  in- 
creased by  advancing  the  handle  of  the  rheostat  until 
about  eight  milliamperes  are  shown  by  the  index  on 
the  dial. 

Within  a  few  seconds  a  white  froth  will  issue  from 
the  follicle,  showing  that  decomposition  of  tissue  is  tak- 
ing place.  The  operator  must  familiarize  himself  with 


the  time  and  amount  of  current  required  to  destroy  super- 
fluous hairs.  Coarse  hairs  may  require  as  much  as  four- 
teen milliamperes,  but  it  is  advisable  to  use  a  moderate 
amount  of  current  and  to  leave  the  needle  a  little  longer 
in  the  follicle  to  avoid  scarring  of  the  skin. 

The  papilla  having  presumably  been  destroyed,  the 
patient  loosens  her  grip  on  the  sponge  and  the  needle 
is  withdrawn. 

The  operator  now  takes  up  an  epilating  forceps,  such 
as  shown  in  Fig.  517,  and  removes  the  hair.  If  the  hair 


FIG.  517. — EPILATING  FORCEPS. 

does  not  come  out  of  the  follicle  readily  it  shows  that 
it  has  not  been  destroyed,  and  the  same  treatment,  just 
described,  must  be  repeated,  but  for  a  shorter  duration. 

When  the  hair  is  removed  it  will  show  more  or  less 
bulb  according  to  its  size  and  nourishment. 

The  physician  now  proceeds  to  remove  the  coarse 
hairs  first.  Hairs  should  not  be  removed  too  closely 
placed,  as  the  current  will  destroy  the  tissue  between  the 
follicle  and  cause  scarring.  It  is  better  to  remove  the 
hairs  some  distance  apart,  leaving  the  remaining  hairs 
for  later  sittings. 

About  forty  or  fifty  hairs  may  be  removed  at  one  sit- 
ting. This  will  require  from  half  to  an  hour  and  a  half 
of  time,  but  the  operator  will  soon  accomplish  consider- 
able work  in  a  minimum  of  time. 

Some  of  the  hairs  removed  will  return,  showing  as 
black  or  dark  specks  in  the  skin,  in  from  five  to  ten  days. 
The  number  returning  depends  on  the  operator's  skill. 
At  first  he  should  not  be  surprised  to  see  fifty  per  cent 
come  back,  but  this  ratio  is  reduced  so  that  only  three 
or  four  hairs  out  of  fifty  may  return,  and  perhaps  these 

stunted  in  growth. 
32 


482      PLASTIC    AND   COSMETIC    SURGERY 

The  electrolytic  removal  of  hair  does  not  stimulate  the 
growth  of  the  finer  hairs  of  the  skin;  that  general  belief 
has  been  erroneous. 

Where  there  is  considerable  hair  to  be  removed,  as 
with  a  beard  on  a  woman's  face,  several  sittings  may  be 
given  a  week  and  at  different  parts  of  the  face,  but  with 
the  average  patient  only  one  sitting  should  be  given  each 
week. 

More  or  less  edema  follows  the  removal  of  hair,  which 
may  remain  for  a  day  or  more.  Warm  applications  will 
help  to  remove  it. 

The  operator  should  at  no  time  state  a  definite  fee  to 
remove  the  hair  on  the  face,  unless  he  is  certain  of  the 
number  present.  Such  judgment  is,  indeed,  very  mislead- 
ing. 

REMOVAL   OF  MOLES   OR  OTHER  FACIAL  GROWTHS 

Moles,  warts,  fibromata,  fungoids,  and  other  excres- 
cences are  best  removed  with  this  method,  especially 
where  they  are  of  the  nonpedunculated  type.  It  is  hardly 
necessary  to  state  that  very  light  currents  should  be  used 
for  the  light  flat  growths,  such  as  a  dark  freckle  or  a 
small  yellow  mole.  The  amount  of  current  required 
varies  from  6  to  24  milliamperes,  according  to  the  size  of 
the  body  to  be  removed. 

The  same  procedure  as  with  the  removal  of  hairs  is 
followed.  Positive  electrode  in  the  hand  of  the  patient, 
negative  pole  to  the  needle  holder.  The  needle  is  thrust 
through  the  growth  on  a  plane  with  the  skin  and  slightly 
above  it.  The  current  will  at  once  produce  a  pale  color 
in  the  mass  and  white  froth  will  issue  about  the  shaft 
of  the  needle.  A  comparatively  greater  amount  of  cur- 
rent is  needed  for  this  purpose  than  with  the  destruction 
of  hairs.  The  operator  must  judge  the  amount  and  time 
required  from  experience. 

The  mass  is  punctured  in  stellate  fashion  to  assure  an 
even  necrosis,  as  shown  in  Fig.  518. 


ELECTROLYSIS    IN    DERMATOLOGY       483 

The  mass  will  appear  much  softer  after  this  treat- 
ment, is  in  some  cases,  as  with  flat  moles,  quite  friable, 
but  this  disappears  in  a  few  hours  and  the  mass  begins  to 


FIG.  518. — ELECTROLYSIS  METHOD  FOR  DESTROYING  GROWTHS. 


shrivel  and  dry  up,  forming  a  scab,  which  is  between 
brown  and  almost  black  in  color.  This  scab  falls  off  in 
several  days,  according  to  its  size,  leaving  a  pink  eschar, 
which  gradually  turns  white  and  shows  very  little,  if  the 
growth  has  not  been  too  large  and  the  electrolysis  care- 
fully done.  If  little  tumefactions,  or  tips  of  tissue,  still 
appear,  they  are  removed  as  soon  after  the  scab  falls  off 
as  deemed  advisable  by  the  same  method.  Warts  show 
more  or  less  recurrence. 


TELANGIECTASIS 

In  this  condition  there  appear  in  the  skin  one  or  many 
dilated  capillaries.  It  is  quite  common  about  the  sides 
and  lobule  of  the  nose  and  just  inferior  to  the  malar 
prominence  of  the  cheeks.  To  destroy  these  the  fine  plat- 
inum needle  is  thrust  through  the  skin  and  directly 
through  the  canal  of  the  vessel.  The  same  disposition 
of  the  electrode  is  used  as  heretofore  described. 

Immediately  the  current  is  made,  a  series  of  bubbles 
of  hydrogen  will  run  through  the  vessel  which  presently 
becomes  pale  and  empty,  as  a  result  of  the  electro- 
chemical action. 


484      PLASTIC    AND    COSMETIC    SURGERY 

The  needle  .should  be  allowed  to  remain  in  the  ves- 
sel from  five  to  ten  seconds,  according  to  the  size  of  the 
latter. 

The  object  is  to  set  up  sufficient  irritation  in  and  of 
the  walls  of  the  vessel  so  as  to  occlude  it  when  cicatriza- 
tion has  been  established.  Some  edema  follows  such  a 
treatment,  subsiding  in  a  day  or  more.  Several  vessels 
may  be  treated  in  the  same  sitting,  and  at  either  side  of 
the  face.  The  operator  should  guard  against  too  strong 
a  current,  to  avoid  scarring  of  the  skin.  The  final  result 
in  this  treatment  shows  fine  punctate  scars,  as  after  the 
removal  of  coarse  hairs,  and  sometimes  pale  linear  scars, 
but  these  are  observable  only  on  close  inspection. 

REMOVAL  OF  N^EVI 

Birthmarks,  port-wine  marks,  and  other  pigmentary 
conditions  may  be  entirely  or  partly  removed  from  the 

skin  of  the  face,  accord- 
ing to  the  size  of  the 
area  treated  and  the  na- 
ture of  the  case.  For 
this  purpose  the  single 

FIG.  519. — MULTIPLE  NEEDLE  -,-,  i      j 

ELECTRODE.  needle    attached    to    the 

negative   pole   is   hardly 

sufficient,  unless  the  spot  is  exceedingly  small,  there- 
fore a  bunch  needle  electrode  is  used.  This  electrode 
has  a  number  of  fine  steel  needles  set  into  it,  as  shown 
in  Fig.  519. 

In  this  treatment  the  needles  are  made  to  puncture 
the  skin  at  right  angles  to  them  to  a  depth  corresponding 
to  the  papillary  layer.  These  pigments  lie  above  that, 
so  that  it  is  not  necessary  to  include  the  derma.  At  each 
point  of  puncture  a  white  spot  will  appear  which  soon 
turns  red.  In  a  day's  time  a  number  of  fine  scabs,  or  a 
single  scab,  will  form  over  the  parts  treated,  which  fall 
away  in  about  five  days  eventually,  leaving  the  parts 


ELECTROLYSIS    IN    DERMATOLOGY       485 

paler  than  before,  owing  to  a  number  of  minute  punctate 
scars. 

The  amount  of  treatment  given  in  each  case  varies 
with  the  extent  of  the  lesion.  If  the  result  from  the  first 
sitting  has  not  accomplished  as  much  as  desired,  it  can  be 
repeated  over  and  over  until  the  parts  assume  a  normal 
tint.  There  may  be  more  or  less  bleeding  following  the 
treatment ;  this  is  easily  checked  by  pressure.  If  the  part 
worked  on  is  quite  large,  dry  aristol  dressing  should  be 
used  to  avoid  infection.  The  scab  should  not  be  picked 
off  by  the  patient,  but  allowed  to  fall  off. 

REMOVAL  OF  TATTOO    MARKS 

The  best  method  of  removing  such  pigmentations  of 
the  skin  is  to  remove  them  with  the  knife  when  possible, 
and  to  cover  the  wound  by  sliding  flaps  made  by  sub- 
cutaneous dissection  at  either  side  of  the  wound,  as  in 
the  Celsus  method.  Some  authorities  advocate  their  re- 
tattooing  with  papoid  solution,  while  others  prefer  caus- 
tic agents,  with  the  object  of  destroying  the  pigmented 
area.  These  methods  are  not  to  be  preferred,  since  they 
leave  unsightly  burn  scars. 

Electrolytic  needling  may  be  tried  and  is  quite  success- 
ful when  the  marks  are  very  small,  but,  as  with  gun- 
powder stains,  they  are  best  removed  by  punching,  or 
cutting  out,  a  little  cone  of  skin  containing  the  pigment. 
The  secondary  wounds  thus  made  leave  only  very  small 
punctate  scars  that  are  hardly  noticeable.  Of  course  a 
number  of  such  removals  would  not  be  advisable. 

Where  the  pigmentation  is  very  pale,  recourse  may 
be  had  to  the  peeling  method,  as  will  be  later  described. 

THE  TREATMENT   OF   SCARS 

Not  infrequently  the  cosmetic  surgeon  is  called  upon 
to  remove  or  improve  unsightly  scars  about  the  face, 


486      PLASTIC    AND    COSMETIC    SURGERY 

the  result  of  injuries  or  burns  and  after  the  careless  co- 
aptation  of  such  wounds.  The  scars  vary  in  extent  and 
degree,  from  a  mere  pit  due  to  varicella  or  variola  to 
the  broad  areas  following  the  cicatrization  of  lupus  and 
burns.  Surgical  scars  vary  also  from  a  mere  line  to 
areas  of  greater  or  less  extent,  dependent  upon  the  abla- 
tion of  neoplasms  or  the  granulation  of  wounds  due  to 
any  cause. 

The  treatment  of  scars  depends  upon  their  size  and 
location.  A  mere  linear  scar  may  be  reduced  by  elec- 
trolysis, the  needle,  negative  pole,  being  introduced  equi- 
distantly,  from  one  sixteenth  to  a  quarter  inch  apart, 
with  the  hope  of  causing  a  breaking  down  electro- 
chemically  of  the  scar  itself  and  waiting  for  secondary 
cicatrization.  In  other  words,  making  a  scar  within 
a  scar. 

This  mode  of  treatment  may  be  repeated  in  two  or 
three  weeks  and  has  the  tendency  of  breaking  up  the 
shiny  line  of  light  that  makes  the  scar  stand  out  promi- 
nently from  the  skin. 

Such  scars,  where  nonadherent,  or  flat  with  the  plane 
of  the  skin,  may  also  be  tattooed  to  reduce  their  white 
color. 

For  this  purpose,  the  red  or  carmine  pigment  used  for 
tattooing  is  diluted  and  pricked  into  the  scar  tissue  with 
a  fine  cambric  needle  by  hand  or  electric  process. 

When  the  scar  is  small  the  line  is  punctured  here  and 
there  and  the  aqueous  solution  of  the  pigment  is  painted 
over  the  area,  which  is  again  worked  over  to  make  it 
take. 

For  larger  scar  surfaces  multiple  needles  are  used. 
These  are  composed  of  from  four  to  ten  needles  soldered 
together  at  their  eye  ends,  leaving  the  points  at  an  even 
level. 

The  electric  method  is  the  most  serviceable  for  tat- 
tooing large  scars. 

These  instruments  are  electro-magnetic  devices  made 


ELECTROLYSIS    IN    DERMATOLOGY       487 

to  accommodate  single  or  multiple  needle  points  and  can 
be  obtained  from  instrument  makers. 

The  author  has  had  a  special  electric  synchronous 
reciprocal  apparatus  made,  as  here  shown  in  Pig.  520, 


FIG.  520. — AUTHOR'S  ELECTBIC  APPARATUS  FOR  TATTOOING  SCARS. 

which  is  much  more  compact  than  the  ordinary  electric 
apparatus  found  on  the  market.  It  works  on  the  prin- 
ciple of  the  sewing  machine  needle. 

In  using  the  electric  apparatus  the  needle  ends  are 
dipped  into  the  pigment  paste,  to  which  a  little  glycerin 
is  added  to  bind  it,  and  this  is  tattooed  or  pricked  into 
the  scar. 

If,  after  the  parts  are  healed,  the  color  is  too 
light,  the  scar  may  again  be  gone  over  until  the  tint 
matches  somewhat  the  tint  of  the  skin.  Other  pig- 
ments may  be  used,  according  to  the  complexion  of  the 
patient. 

Some  scars,  the  resultant  of  negligent  coaptation,  are 
to  be  excised  according  to  the  Celsus  method  and  are 
brought  together  with  a  number  of  fine  silk  sutures. 

If  the  skin  is  found  to  be  attached  too  closely  to  the 
subcutaneous  structure,  it  must  be  dissected  up  to  render 
it  mobile. 

When  the  scar  cannot  be  removed  by  excision  the  hy- 
podermic use  of  thiosinamin  may  be  tried. 

Thiosinamin  or  rhodallin  is  only  slightly  soluble 
in  water,  but  the  addition  of  antipyrin  according  to 
Michel  renders  it  useful  for  hypodermic  use.  The  for- 
mula preferred  by  the  author  is  made  as  follows : 


488      PLASTIC    AND    COSMETIC    SURGERY 

ly   Tliiosinaimn grs.  ij 

Antipyrin    grs.  j 

Aqua  dest gtts.  xx. 

The  above  solution  makes  up  a  single  injection,  which 
is  to  be  made  directly  under  the  scar  or  into  the  muscu- 
lar tissue  below  it.  Two  injections  are  given  each  week. 

The  treatment  is  to  be  continued  until  the  texture  of 
the  cicatrix  is  equal  to  that  of  the  skin. 

These  injections  are  more  or  less  painful  and  may 
be  supplanted  to  advantage  with  the  hypodermic  use 
of  fibrolysin  (Mendel),  in  which  each  2.3  e.c.  corre- 
spond to  three  grains  of  thiosinamin. 

For  very  small  scars,  as  those  occasioned  by  blepharo- 
plastic  operation,  the  author  employs  the  twenty-per-cent 
thiosinamin  plaster  mull  made  by  Unna.  These  are  to 
be  applied  every  day  or  night,  according  to  the  conven- 
ience of  the  patient,  and  allowed  to  remain  on  for  sev- 
eral hours  each  day. 

At  first  these  plaster  mulls  are  inclined  to  cause  ery- 
thema and  exfoliation  of  the  epithelium,  therefore  they 
might  be  used  on  alternate  days  to  keep  the  parts  more 
sightly. 

For  scars  of  large  extent  the  above  method  will  an- 
swer best.  If  there  is  considerable  contraction,  the 
parts  should  be  massaged  daily  to  soften  and  stretch 
them.  Eventually  the  depression  of  contour  may  be 
corrected  by  hydrocarbon  protheses  introduced  subcu- 
taneously  following  subcutaneous  dissection,  if  deemed 
necessary. 

Small  pits,  where  discrete,  are  best  removed  with  a 
fine  knife  and  brought  together  by  a  fine  suture  which  is 
to  be  removed  on  the  fifth  day. 

Confluent  pittings,  as  after  variola,  must  be  removed 
by  decortication  or  peeling  methods. 

The  pits,  if  spread  about  the  face  promiscuously,  may 
be  treated  separately  by  the  peeling  method,  but  when 


ELECTROLYSIS    IN    DERMATOLOGY       489 

they  lie  less  than  one  inch  apart,  it  is  best  to  treat  the 
skin  of  the  whole  face. 

This  is  done  by  applying  pure  liquid  carbolic  acid  to 
the  skin  with  a  cotton  swab.  The  skin  at  once  assumes  a 
white  color.  If  the  pittings  are  not  very  deep,  one  ap- 
plication of  the  acid  is  sufficient.  If  deep,  one  or  two 
more  applications  are  made  as  the  preceding  one  dries. 
In  very  deep  pits,  the  surgeon  should  apply  the  acid  to 
the  pit  proper  several  times,  blending  off  the  application 
at  the  periphery. 

When  the  surface  thus  treated  has  become  dry,  adhe- 
sive plaster,  cut  in  half-inch  strips  of  desirable  length, 
are  put  on  the  face,  one  above  the  other,  slightly  overlap- 
ping, until  the  whole  treated  surface  is  well  covered, 
mask-like. 

The  author  uses  Unna's  zinc  oxide  plaster  mull  for 
this  purpose,  as  it  is  backed  with  gutta-percha,  which 
readily  adapts  itself  to  the  curvatures  of  contour. 

The  adhesive  plaster  mask  is  not  removed  until 
about  the  fourth  or  fifth  day,  when  it  will  be  prac- 
tically forced  away  from  the  skin  by  the  excretions 
thrown  out  from  the  derma.  In  some  cases  there  is 
considerable  pus. 

After  removal  of  the  mask  the  skin,  now  very  red 
and  tender,  is  cleansed  with  a  solution  of  bichloride,  1  in 
10,000. 

After  the  cleansing  a  mild  soothing  ointment,  such  as 
zinc  oxide  in  vaselin,  is  used  for  several  days  until  the 
skin  takes  on  its  normal  epitheliar  layer  and  appears 
normal  in  color. 

No  water  or  soaps  are  to  be  allowed  during  the  lat- 
ter period.  In  the  later  days  of  the  treatment  the  skin 
may  be  cleansed  with  a  little  borated  vaselin  or  even 
olive  oil  used  with  absorbent  cotton. 

If  there  is  a  pigmentation  of  the  new  skin  this 
should  cause  no  alarm,  as  it  will  fade  out  in  from  six  to 
eight  weeks. 


490      PLASTIC    AND    COSMETIC    SURGERY 

Tincture  of  iodine  has  been  used  for  the  same  pur- 
pose, as  well  as  its  mixture  with  carbolic  acid. 

Resublimed  resorcin  is  also  advocated,  but  the  result- 
ant peeling  will  not  prove  thick  enough  to  give  a  satis- 
factory result. 

If,  for  any  reason,  the  effect  obtained  is  not  as  de- 
sired, the  patient  should  wait  for  several  weeks  and  have 
the  treatment  repeated. 

It  is  hardly  necessary  to  say  that  the  application  used 
should  not  get  into  the  eyes.  The  upper  eyelids  should 
not  be  treated,  since  no  benefit  arises  from  it.  If  there  is 
a  redundancy  of  tissue,  it  should  be  removed  surgically, 
as  heretofore  described. 


CHAPTER    XVIII 
CASE   KECORDING   METHODS 

EVERY  case,  whether  of  little  consequence  or  of  im- 
portant nature,  should  be  properly  and  fully  recorded  in 
a  thorough  and  systematic  manner.  Apart  from  the 
value  of  such  a  record,  to  the  operating  surgeon  it  often 
proves  of  the  greatest  importance  in  cases  where  opera- 
tions of  a  purely  cosmetic  nature  are  undertaken. 

Patients  who  beg  us  to  make  them  more  beautiful, 
or  less  unsightly  in  the  eyes  of  the  ever-critical  observer, 
are  the  most  difficult  to  please,  and  often  complain,  after 
a  few  days  of  constant  mirror  study,  of  the  parts  changed 
by  methods  that  are  the  result  of  years  of  hard-earned 
experience,  that  the  nose  or  the  eyes  or  the  ears  have  not 
been  changed  as  much  as  they  desired — in  fact,  so  little 
that  their  closest  friends  have  failed  to  evoke  ecstatic 
remarks  about  the  improvement. 

This  is  not  unusual  with  the  most  intelligent  patients 
and  is  due  to  the  fact  that  cosmetic  operations  performed 
on  an  ugly  though  otherwise  normal  organ  have  not 
yet  become  very  frequent,  and  while  friends  are  inclined 
to  remark  a  change  in  lesser  defects,  they  fail  to  credit 
this  to  the  cause,  owing  to  a  lack  of  the  knowledge  of  cos- 
metic surgery,  or  their  ignorance  of  the  art  entirely. 

Photographs, — Where  a  pathological  defect,  wound,  or 
scar  or  traumatic  deformity  is  to  be  corrected,  the  pa- 
tient is  usually  kind  enough  to  permit  of  photographs 
being  made  of  the  parts  to  be  operated  on,  but  where  the 
defect  is  hereditary,  or  the  result  of  age,  objections  are 

491 


492      PLASTIC    AND    COSMETIC    SURGERY 


invariably  raised  by  all  concerned,  for  fear  their  pictures 
will  be  used  in  some  outlandish  way. 

The  objection  to  photographs  is  obvious,  since  it 
usually  requires  visits  to  a  studio,  and  the  necessary  loss 
of  time  to  the  surgeon,  whose  presence  is  nearly  always 
necessary  to  secure  the  proper  negative. 

This  is  especially  true  of  the  nose.  Very  few  pho- 
tographers will  make  a  satisfactory  sharp  profile  picture. 
It  is  less  artistic,  but  most  desired  by  the  surgeon,  and 
when  the  patient  is  presented  for  a  second  negative  after 
the  operation  has  been  performed,  the  picture  varies 
more  or  less  in  pose  from  the  first  taken. 

It  would  be  well  for  physicians  to  have  a  camera  for 
use  in  the  operating  room,  and  those  who  can  manipulate 
one  will  find  that  taking  a  5  X  7  negative  the  most  suit- 
able. 


FIG.  521. — NOSE  STENCIL. 


Stencil  Record. — For  those  who  cannot  provide  them- 
selves or  bother  with  a  photographic  apparatus,  the  sten- 
cil record  is  recommended. 

For  this  purpose  a  picture  of  a  normal  eye  and  its 


493 

lids,  a  nose,  lip  or  ear,  is  drawn  upon  a  piece  of  oiled  or 
stencil  paper,  or  upon  any  thick,  stiff  book  board. 

The  paper  is  laid  down  upon  a  plate  of  glass  and  the 
outlines  of  the  picture  are  cut  out,  wide  enough  to  allow 
the  sharpened  point  of  a  pencil  to  pass.  Where  the  lines 
are  long  it  is  advisable  to  allow  connecting  links  to  re- 
main at  various  intervals  as  desired  to  keep  the  stencil 
stiff  and  to  prevent  cut  margins  from  slipping  or  roll- 
ing up.  (See  Fig.  521.) 

The  stencil  thus  made  is  laid  upon  the  record  card 
and  a  tracing  is  made  upon  the  latter  by  passing  the 
lead-pencil  point  along  the  cut  outline. 

The  stencil  is  now  lifted  and  the  defect  sketched  into 
the  picture  of  the  normal  organ. 

If  this  should  be  the  anterior  nasal  line,  a  perfect 
sketch  can  be  made  of  the  defect  by  placing  a  card  along- 
side of  that  organ  and  drawing  the  outline  upon  it  as  the 
pencil  is  made  to  glide  over  the  nose,  the  point  facing  the 
card  in  such  a  way  that  a  true  profile  outline  is  obtained. 
The  card  is  then  cut  along  the  pencil  line. 

The  nasal  section  of  the  card  is  now  placed  upon  the 
stenciled  nose  and  its  outer  border  traced  into  or  over  it, 
as  the  case  may  be,  by  drawing  the  pencil  point  along  the 
outer  margin. 

The  same  method  may  be  followed  post-operatio. 
This  method  can  be  employed  for  the  other  parts  of  the 
face  as  well,  as,  for  instance,  the  mouth,  ears,  base  of 
nose,  etc. 

Distances  in  measurements  should  be  put  into  the 
record  drawing  to  make  it  more  exact. 

The  Rubber  Stamp. — Another  method  is  to  make  outline 
sketches  of  normal  parts  of  the  face  with  India  ink  upon 
drawing  board  and  have  those  reproduced  in  rubber 
stamps,  using  the  stamp  in  place  of  the  stencil  and  mark- 
ing in  the  defect  in  the  manner  before  mentioned. 

The  Plaster  Cast. — The  best  method  by  far,  however,  and 
the  one  found  most  accurate,  is  the  plaster  cast.  It  is  not 


494      PLASTIC    AND    COSMETIC    SURGERY 


a  difficult  thing  to  make  a  cast  of  a  nose,  eyelid,  lip,  or 
ear,  and  the  latter  is  much  more  preferable  to  any  other 
method  of  record. 

For  this  purpose  some  modeling  clay  is  required, 
which  is  molded  into  a  strip  and  laid  around  the  part  to 
be  reproduced. 

This  forms  a  sort  of  raised  ring  or  border  and  pre- 
vents the  overflow  of  the  semiliquid  plaster,  and  avoids 

the  annoyance  of  trick- 
ling the  liquid  upon 
other  parts  of  the  face 
about  the  site  of  the 
part  worked  on;  at  the 
same  time  it  permits  of 
neatness  and  uniformity 
in  the  size  and  shape 
of  the  casts  to  be  filed 
away  as  records.  (See 
Fig.  522.) 

The  skin  surface, 
and  hair,  if  any,  within 
this  ring  area,  before 
using  this  plaster  of 
Paris,  is  now  thorough- 
ly coated  with  clean  oil, 
or  petrolatum,  applied  with  a  soft  sable  brush.  The 
inner  and  upper  part  of  the  wax  ring  is  also  coated. 

If  there  are  openings  in  the  parts  of  the  face,  such 
as  the  nostrils  or  the  auricular  orifice,  they  should  be 
plugged  lightly  with  dry  absorbent  cotton,  care  being 
taken,  however,  to  avoid  distending  the  alae. 

The  plaster  is  now  prepared  in  a  small  porcelain  or 
soft  rubber  bowl  by  adding  warm  water  to  it  until  the 
powder,  upon  stirring,  forms  an  even  semiliquid  paste. 
This  is  poured  first  upon  the  area  to  be  reproduced  to 
fill  all  the  finer  crevices  and  to  avoid  air  holes,  and  is 
then  put  on  with  a  spatula,  or  wooden  slab,  until  the 


FIG.  522. — METHOD  OF  MAKING  NASAL 
PLASTER  CAST. 


CASE    RECORDING    METHODS  495 

space  within  the  clay  boundary  is  properly  filled,  cover- 
ing the  organ  all  over  with  a  layer  5  to  ^  inch  in  thick- 
ness on  all  sides.  Over  the  eyelids  a  thin  coating  of 
plaster  should  be  used,  whereas  over  other  parts  of  the 
face  a  thickness  of  half  an  inch  can  be  allowed  without 
discomfort  to  the  patient. 

It  is  well  at  first  to  make  the  plaster  thick,  as  the 
mold  is  liable  to  be  broken  upon  removal  or  in  drying. 
After  a  little  experience  splendid  results  are  obtained 
with  very  thin  walls  of  plaster. 

The  plaster  is  allowed  to  dry  and  harden,  white  the 
patient  is  instructed  to  remain  still  and  silent.  If  a 
cast  of  the  nose  is  made,  the  patient  should  refrain  from 
talking  and  breathe  gently  through  the  mouth. 

Tapping  on  the  plaster  now  and  then  with  a  lead  pen- 
cil will  show  when  it  has  hardened  sufficiently  to  be  re- 
moved. 

A  firm,  quick  pull  relieves  the  mold. 

In  molds  of  the  ear  an  anterior  and  posterior  im- 
pression should  be  made,  if  a  cast  of  the  entire  organ 
is  desired.  This  can  be  done  by  first  applying  a  layer  of 
plaster  to  the  posterior  surface  up  to  the  outer  rim,  al- 
lowing this  to  harden  and  painting  the  anterior  ear  and 
the  exposed  plaster  border  with  petrolatum  before  put- 
ting the  plaster  over  it.  Upon  traction,  when  set,  the 
plaster  will  separate  readily  at  the  point  of  the  separa- 
tion. 

The  removed  piece  of  set  plaster  is  called  the  mold. 

It  is  allowed  to  dry  thoroughly  and  then  preferably 
coated  inside  with  a  thin  coat  of  liquid  petrolatum, 
which  is  found  to  be  much  better  than  oil. 

A  thinly  prepared  paste  of  plaster  is  poured  into  it 
at  the  outer  brim  and  allowed  to  harden.  The  best  re- 
sults are  obtained  by  setting  the  mold  into  a  small 
pasteboard  box  in  which  it  is  held  in  proper  position  and 
prevents  the  .thin  plaster  from  running  over  the  de- 
pressed edges. 


496      PLASTIC   AND    COSMETIC    SURGERY 

By  gently  tapping  the  mold  when  the  cast  has  set,  it 
is  made  to  separate  from  the  latter  sufficient  to  per- 
mit of  separating  or  cutting  away  of  the  mold  inside 
of  it. 

The  cast,  when  removed  and  dry,  is  coated  with  white 
shellac  varnish.  Upon  its  reverse  side  a  note  is  scratched 
into  it,  giving  the  case  number,  or  such  information  as 
the  surgeon  may  desire. 

The  author  advises  the  addition  of  a  small  quantity 
of  Armenian  bole  to  the  plaster  used  for  the  cast,  as  it 
gives  a  less  ghastly  tint  and  aids  much  by  its  color  in 
the  cutting  away  of  the  white  mold  from  the  cast.  Sev- 
eral of  these  casts,  taken  before  and  after  operation  by 
the  author,  have  been  shown  in  the  preceding  chapters. 

After  operation  and  healing  of  the  parts  a  second 
cast  is  made. 

Hooks  can  be  inserted  into  the  casts,  when  still  soft, 
to  hang  them  up  by,  or  loops  of  string  or  wire  are  stuck 
into  them,  while  setting  for  the  same  purpose. 

Such  a  collection  is  not  only  of  great  value  to  the  op- 
erator, but  is  a  means  of  constant  and  absolute  record, 
even  to  the  extent  of  reproduction  by  photography. 

The  necessary  data  in  respect  to  the  method  employed 
in  operating,  dressing,  etc.,  is  to  be  added  to  the  record 
as  generally  done  with  medical  or  other  surgical  causes. 

Preparation  of  Photographs. — There  are  some  cases  of 
which  no  other  permanent  record  can  be  made,  except 
by  photograph.  If  these  can  be  obtained,  the  negatives 
are  to  be  printed  without  retouching,  the  prints  being 
made  on  silver  printing  paper  of  the  glossy  type  to  per- 
mit of  reproduction  in  half-tone  when  desired  at  some 
future  time. 

In  printing  such  pictures,  the  eyes,  or  other  part  of 
the  face  not  operated  on,  may  be  obliterated  by  laying 
strips  of  paper  next  to  the  negative,  the  part  thus  cov- 
ered coming  out  white  in  the  positive. 

The  photographs  made  of  parts  to  be  operated  on 


CASE    RECORDING    METHODS  497 

should  be  made  as  near  as  the  normal  size,  for  obvious 
reasons  of  accuracy  and  measurement. 

This  can  be  done  by  comparing  the  size  of  the  part  to 
the  picture  found  on  the  ground  glass. 

Cameras  that  do  not  permit  of  ground-glass  focusing 
are  useless  as  well  as  uncertain.  Time  exposures  are 
necessary  for  the  best  results. 

Dark  backgrounds  should  be  used  to  get  the  sharp 
outlines  by  contrast.  Too  much  light  on  the  parts,  such 
as  direct  sunshine,  is  undesirable,  as  it  makes  the  parts 
appear  flat  and  lifeless;  therefore  a  muslin  screen  is  of 
great  value  to  graduate  the  intensity  of  the  light,  and  if 
this  is  not  at  hand,  a  sheet  of  paper  will  answer  the  same 
purpose. 

In  printing  make  note  of  the  depth  of  color  of  the 
parts  most  desired  to  be  shown,  varying  with  the  differ- 
ent parts  of  the  face.  Look  to  contrast,  and  in  pathologi- 
cal cases  have  the  diseased  area  printed  so  that  it  will 
stand  out  forcibly  as  compared  to  the  fellow  organ  in 
health  or  the  normal  tissue  beyond  its  border. 

To  protect  photographic  records,  they  should  be  prop- 
erly bound  in  book  fashion  to  avoid  scratching,  rubbing, 
or  breaking.  This  not  only  implies  neatness  and  thor- 
oughness on  the  part  of  the  surgeon,  "but  also  permits  of 
ready  reference  at  all  times. 

An  index  to  the  contents  of  such  a  book  is  a  desirable 
adjunct. 


33 


INDEX  TO   AUTHORS 


ADAMKIERWICZ,  osteoplasty,  101. 

D'ALQUIE,    rhinoplasty,    360. 

ALLIOT,  history  of  reparative  sur- 
gery, 5. 

ALLIS,  inhaler,  65. 

VON  ALLTMANN,  bioblasts,  100. 

ALTER,  partial  stenosis  of  nares 
after  paraffin  injection,  229. 

AMMON,  blepharoplasty,  108. 

VON  AMMON,  rhinoplasty,  358. 

ANGERER,  antiseptics,  38. 

VON  ARTIIA,  blepharoplasty,  112. 

AUVERT,  rhinoplasty,  359. 

BARATOUX,  paraffin  injections,  210. 

skin  grafting  method,  99. 
BARDELEBEN,  antiseptics,  40. 

sutureless  blepharoplasty,  119. 
BARDENIIEUER,  meloplasty,  203. 

rhinoplasty,  416. 
BARTLEY,  antiseptics,  37. 
BAUMAN,  antiseptics,  37. 
BAYER,  meloplasty,  201. 
BAYER-PAYR,  rhinoplasty,  424. 
BECK,  peroxoles,  41. 
BEINL,  hare-lip  clamp,  145. 
BENNETT,  cocain,  70. 
BERGER,  cheiloplasty,  183. 

classiflcation    of    lip    deformities, 
162. 

nasal  retention  apparatus,  385. 

rhinoplasty,  384,  424. 
VON  BERGMAN,  antiseptics,  38. 

history  of  plastic  surgery,  7. 

operating  gown,  19. 
BILLROTU,  antiseptics,  38,  40. 

carcinoma  of  lips,  168. 

combined  anesthesia,  67. 


BLANDIN,  history  of  reparative  sur- 
gery, 5. 
rhinoplasty,  435,  444. 

BLASIUS,  cheiloplasty,  177. 
rhinoplasty,  303,  367. 

BOECKMAN,    preparation   of   catgut, 
32. 

BOJANIS,  history  of  rhinoplasty,  3. 

BONNET,  rhinoplasty,  434. 

BOUILLON,  antiseptics,  40. 

BRANCA,  history  of  rhinoplasty,   3, 
349. 

BRANCA,     ANTONIUS,      history      of 
rhinoplasty,   3. 

BRETZ,  sutureless  coaptation,  48. 

BRINDEL,  facial  phlebitis  after  par- 
affin injection,  226. 
paraffin  injection,  210. 

BRCECK^RT,    antiseptic    with    par- 
affin, 218. 

facial  phlebitis  after  paraffin  in- 
jection, 226. 
paraffin  injection,  210. 

BRUNS,  cheiloplasty,   163,  171,   175. 

BRYANT,  antiseptics,  39. 

BUCHANAN,  cheiloplasty,  176. 

BUCHHOLTZ,  antiseptics,  38. 

BUCK,  cheiloplasty,  165,  172. 

BULL,  epicanthus,  113. 

BUNGER,   history  of  rhinoplasty,   5, 
350. 

BURCHARDT,     compressing     forceps, 
145. 

BURNETT'S  fluid,  41. 

BURNS,  charpie  cotton,  67. 
flap  method,  86. 

BURON,  antiseptics,  35. 
cheiloplasty,  178. 

499 


500 


INDEX    TO    AUTHORS 


BiJROx,  rhinoplasty,  05. 

sliding  flap  method,  85. 
Birscn,  rliinoplasty,  430,  433. 

CAEPUE,  history  of  rliinoplasty,  4. 
DE  CAZENEUVE,  facial  phlebitis  after 

paraffin  injection,  226. 
hot-water  jacket  for  syringe,  233. 
CELSUS,  ATJLUS  CORNELIUS,   cheilo- 

plasty,  169. 
"  Father     of     Plastic     Surgery," 

frontispiece. 

history  of  plastic  surgery,  1. 
skin  incisions,  80,  485,  487. 
CHARRIERE,  nasal  prothesis,  348. 
CHELIUS,  replantation  of  nose,  349. 
CHEYNE,  injection  of  paraffin,  210. 
CLARK,    J.    G.,    Kumol    apparatus, 

32. 
COMSTOCK,    disposition    of    injected 

paraffin,  235,  236. 
effect  of  paraffin  on  animals,  225. 
melting  point  of  paraffin,  241. 
CONDY,   fluid   of,  40. 
CONNELL,  injection  of  paraffin,  210, 

230. 

COPELAND,    history    of    plastic    sur- 
gery, 7. 

CORNING,  injection  of  oils,  209. 
COSTA,  temperature  of  cocain  solu- 
tion, 72. 

CZERNY,     history     of     plastic     sur- 
gery, 6. 
sterilization  of  silk,  30. 

DAWBARN,   preservation  of  needles, 

16. 

DAVIDSOHN,  care  of  instruments,  15. 
DAVY,  Sir  H.,  nitrous  oxid,  67. 
DEBOUT,  nasal  prothesis,  348. 
DELAIN,   vaselin   injections   in   ani- 
mals, 217. 

DELANGRE,  nasal  prothesis,  209. 
thermoform     sleeve     for     syringe, 

233. 

DELPECH,  cheiloplasty,  181. 
history  of  rhinoplasty,  5. 
rhinoplasty,  353. 


DENONVILIIER,  rhinoplasty,  428,  430, 

438. 
DIEFFENBACH,    blepluiroplasty,    104, 

105,    109. 

cheiloplasty,  157,  164,  173,  187. 
history  of  reparative  surgery,  5. 
microstoma,  195. 

rhinoplasty,    357,    372,    431,    44(5, 
466. 

DlEFFKNBACH  -         VON         LAGKNBACTI, 

stomatoplasty,   193. 

DOBOUSQUET,  skin  grafting  method, 
99. 

DOWNIE,  celloidin  in  protheses,  use 

of,  228. 
electrothermic      syringe       heater, 

233. 

paraffin    injection    on    carcinoma, 
effect  of,  235. 

DREESMANN,  history  of  plastic  sur- 
gery, 7. 

DUBERWITSKY,  rhinoplasty,   356. 

DUNBAR,    vaselin   injection    in    ani- 
mals, 217. 

DUPUYTREN,    rhinoplasty,   431,    445. 

ECKSTEIN,    absorption    of    paraffin, 

220. 
encapsulation  of  injected  paraffin, 

234. 

Hart-paraffin,  210. 
rubber  insulator  for  syringe,  231, 

263. 

EICHHOFF,  arjstol,  41. 
ENGEL,  median  cleft  harelip,  148. 
ERICHSEN,    JOHN   ERIC,    history    of 

plastic  surgery,  6. 
ESCHWEILER,   new  tissue   formation 

after  paraffin  injection,  237. 
oft-repeated  injection,  215. 
VON  ESMARCH,  antiseptics,  40. 
cheiloplasty,  158. 
dropping  bottle,  60. 
inhaler,  60. 
number  of  rhinoplastic  operations 

required,  347. 

ESTLANDER,  cheiloplasty,  171. 
ESTLANDER-ABBE,  cheiloplasty,  166. 


INDEX    TO    AUTHORS 


501 


EWALD,      thermoform      sleeve      for 

syringe,  233. 
EWAIJD-ALBERT,  meloplasty,  199. 

FABRICIUS,  history  of  rhinoplasty,  3. 
FAIIRIZI,  rhinoplasty,  375. 
FAHREXBACH,  bilateral  cleft,  158. 
FEIILEISEN,  erysipelo-coccus,  50. 
FEINBERG,   ainyl  nitrate   inhalation, 

71. 

FKRRKOL,  iodoform,  42. 
FILLEBROWN,  cheiloplasty,  152. 
FISHER,  osteoplasty,  102. 
FOURGUE,  rhinoplasty,  359. 
FOURXEAU,  stovain,  75. 
FOWLER,  inhaler,  66. 
FREEMAN,  blunt  needle  for  paraffin 

injection,  227. 
early      encystment      of      paraffin, 

235. 

FRICKE,  blepharoplasty,  108. 
vox  FRISCII,  subcutaneous  prothesis, 

209. 
FRITZ-REICH,  rhinoplasty,  431. 

GADEKE,  cocain,  70. 
GARRE,  skin  grafting  method,  93. 
GARTNER,  care  of  instruments,   15. 
GAUTHIER,  cocain  solution,  72. 
GELEY,  antithermics,  57. 
GEXSOUL,  rhinoplasty,  465. 
GERSITNY,    correction    of    labial    de- 
fect, 185. 

duration     of     paraffin     protheses, 
238. 

encapsulation  of  vaselin,  234. 

history  of  rhinoplasty,  8. 

meloplasty,  201. 

mucosa  grafting,  101. 
GEUZMER,  cheiloplasty,  157. 
GLITCH,  antisepsis,  secondary,  57. 

history  of  plastic  surgery,  6,  7. 

ivory  bone  plates,   101. 
GORIS,  rhinoplasty,  387. 
GRAEFE,     history    of     plastic     sur- 
gery, 5. 

rhinoplasty,  352,  374. 
GRAFE,  cheiloplasty,  154. 


GREENE,     correction     of     coloboma, 

125. 

GUERSANT,  bilateral  facial  cleft,  149. 
GUINARD,  antithermics,  5?. 

cheiloplasty,  183. 
GUTCII,  care  of  instruments,   15. 
GUTHRIE,  chloroform  anesthesia,  60. 

history  of  plastic  surgery,  7. 

HAAGEDORN,  catgut  sterilization,  3 1. 
cheiloplasty,  156,  159. 
needle  holder,  78. 
needles,  77. 
VON  HACKER,  rhinoplasty,  391,  436, 

438. 

HAHN,  history  of  plastic  surgery,  7. 
HAIXSLEY,  cheek  compressor,  161. 
HALBAN,      subcutaneous      prothesis, 

209. 

HAMILTON,  injection  of  paraffin,  210. 
HANEL,    quantity    of    cocain    injec- 
tion, 72. 

HARE,  respiratory  forgetfulness,  64. 
HARTMANN,   skin   grafting   method, 

97. 
HASSELMANN,  unilateral  facial  cleft, 

149. 

HAWLEY,  ethyl  chlorid,  68. 
HEATH,    adhesive    plaster    dressing, 

161. 

injection  paraffin,  210. 
HELFERICH,   history  of  plastic  sur- 
gery, 6. 

rhinoplasty,  382,  397. 
VON    HELMONT,    total    rhinoplasty, 

350. 
HERTEL,  chronic  irritation  of  tissue 

after  paraffin   injection,  236. 
HEUTER,  artificial  mouth,   196. 
rhinoplasty,  365. 
stomatoplasty,  196. 
HEYDENREICII,     history     of     plastic 

surgery,  7. 

HILL,  injection  of  paraffin,  210. 
secondary    diffusion    of    paraffin, 

253. 

VON  HIPPEL,  history  of  plastic  sur- 
gery, 7. 


502 


INDEX    TO    AUTHORS 


HIRSCHBERG,    skin-grafting    method, 

107. 

HOFFACKER,  replanting  of  nose,  349. 
HOLDEN,  blindness  following  parallin 

injection,  225. 
HUBSCIIER,     skin-grafting     method, 

94. 
KURD,    blindness    following    paraffin 

injection,  225. 

ISRAEL,,  meloplasty,  202. 
rhinoplasty,  402. 

JACKSON,  ether  anesthesia,  63. 

JAKIMOWITSCH,    history    of    plastic 
surgery,  7. 

JASCHE,  cheiloplasty,  174. 

JENNESCO,  stovain  anesthesia,  75. 

JOBERI,    history    of    reparative    sur- 
gery, 5. 

JUILLAHD,  mask,  66. 

JUKUFF,      disposition     of     injected 

paraffin,  235. 
safety  of  vaselin  injection,  218. 

KALLE,  iodol,  41. 

KARG,  cause  of  skin  pigmentation, 

100. 

KAPSAMMER,  paraffin  injection,  pul- 
monary embolism  after,  224. 
subcutaneous  prothesis,  209. 
KAREWSKI,     hot-water     jacket     for 

syringe,  233. 

subcutaneous  prothesis,  210. 
KEEGAN,  rhinoplasty,  356,  380. 
KERSTEN-MATHIEU,  needle  forceps, 

77. 

KOCH,  antiseptics,  35,  38. 
KOCIIER,  catgut  sterilization,  31. 
KOFMAN,    death    following    paraffin 

injection,  224,  260. 
KOLLE,  blepharoplasty,  113. 
care  of  hands,  18. 
cheiloplasty,  185,  187,  188. 
classification    of    facial    deformi- 
ties, 276. 

classification  of  nasal  deformities, 
212. 


KOLLE,    danger    of    injecting    liquid 

paraffin,  241. 
drop  syringe,  205,  266. 
electric  tattooing  needle,  487. 
electrothermic      paraffin      heater, 

244. 
hyperplasia  and  fibromatosis  after 

paraffin  injection,  256. 
malposition  of  ears,  correction  of, 

139. 

nasal  chisel  and  mallet,  453. 
otoplasty,  124,  135,  137. 
paraffin     mixture     for     injection, 

243. 
rhinoplasty,    437,    440,    452,    454, 

456,  458,  465. 
stomatoplasty,  195. 
KOLLE-PRAVAZ,  syringe,  72. 
KOLLER,  cocain,  70. 
KONIG,  cheiloplasty,  156. 

rhinoplasty,  390,  439. 
KOOMAS,  history  of  rhinoplasty,   4, 

352. 

KOSSMAN,  preparation  of  catgut,  32. 
KRASKE,  antisepsis,  35. 

meloplasty,  201. 

KRAUSE,  history  of  skin  grafting,  6. 
KRAUSE,  F.,  rhinoplasty,  398. 

skin-grafting  method,  91. 
KRONIG,   preparation  of  catgut,   32. 
KRYMOFF,  cocain  solution,  sterilized, 

70. 

KUHNT.  otoplasty,  123. 
KUMMEL,  care  of  instruments,   15. 
KiisTER,  iodoform  collodium,  45. 

rhinoplasty,  423. 
KusTER-lsRAEL,  rhinoplasty,  384. 

LABAT,  rhinoplasty,  255,  363. 
LABORDERIE,  skin  grafting,  99. 
VON    LAIR,   history    of    plastic   sur- 
gery, 7. 

LAKE,  paraffin  injection,  210. 
LANDBEAU,  rhinoplasty,  360. 
vox     LANGENBECK,    blepharoplasty, 
108. 

cheiloplasty,  179. 

history  of  plastic  surgery,  5. 


INDEX    TO   AUTHORS 


503 


VON  LANGENHECK,  rhinoplasty,  35!), 
362,  388,  419,  430,  433. 

VON   LANGENBECK  -  WOLFF  -  SEDILLOT, 
cheiloplasty,  153. 

LANGENBUCH,  antiseptics,  39. 

LANGER,  polyotia,  138. 

LARGER,  cheiloplasty,  182. 

LARREY,  history  of  rhinoplasty,  5. 

LEISER,  collapse  after  paraffin  injec- 
tion, 224. 

LENTENNER,  flap  method,  86. 

LILIENTHAL,  Z.  O.,  aseptic  plaster, 
47. 

LINHART,  rhinoplasty,  363,  466. 

LISFRANC,  history  of  rhinoplasty,  5. 
rhinoplasty,  253. 

LITTLEWOOD,    fixation   of   elhows   in 
cheiloplasty,  153. 

LISTER,  J.,  antiseptics,  34,  35. 
catgut  preparation,  31. 
history  of  antisepsis,  5. 
protective  silk  plaster,  47. 

LOVE,  antiseptics,  39. 

LUSK,  Z.,  skin-grafting  method,  96. 

LYNCH,  subcutaneous  prothesis,  210. 

LYNN,  history  of  rhinoplasty,  4. 

MAAS,  antiseptics,  35,  40. 

cheiloplasty,  156,  159. 
MACEWEN,     history     of     reparative 

surgery,  7. 
osteoplasty,  101. 
MAISONNEUVE,  rhinoplasty,  368. 
MALGAIGNE,  cheiloplasty,  154. 
history  of  plastic  surgery,  2. 
MALPIGHIAN,  skin  layer  of,  89. 
VON  MANGOLD,  cartilaginous  support 

in  rhinoplasty,  405. 
MARTIN,  nasal  prothesis,  348,  388. 
MATIIIEU,  nasal  prothesis,  248. 
MAYO,  saline  injection  in  protheses, 

275. 
MENDEL,  injection  of  fibrolysin,  197, 

488. 

MERLING,  beta  eucain,  74. 
MEYER,  WILLY,  sterilizer,  24. 
vaselin      injection      in      animals, 
217. 


MICHEL,    time    required    to    replace 

injected  mass,  238. 
MIKULICZ,  use  of  iodoform,  42. 
MINTZ,  blindness   following  parafVm 

injection,  226. 

MIRAULT-BRUNS,  cheiloplasty,  155. 
MONGITORE,   history  of   rhinoplasty, 

3. 
LE    MONIER,    history    of    reparative 

surgery,  5. 
MONK,  correction  of  malposcd  ears, 

139. 

rhinoplasty,  450. 
MORGAN,  antiseptics,  40. 

cheiloplasty,  180. 
MORRIS,  prothesis  for  cheek,  207. 
MORTON,  ether  anesthesia,  63. 

time  required  to  replace  injected 

paraffin,  238. 
MOSETIG-MOORHOF,  history  of  plastic 

surgery,  8. 
MOSZKOWICZ,    injection    of    vaselin 

harmless,  210. 
pulmonary  embolism  after  paraffin 

injection,  224. 
thermoform    sleeve     for    syringe, 

233. 

MULE,  history  of  plastic  surgery,  8. 
MUTTEB,     history     of     plastic     sur- 
gery, 5. 
rhinoplasty,  429,  433. 

NELATON,  cheiloplasty,  152. 

rhinoplasty,  364,  400,  406,  433. 
NELATON,     CH.,     rhinoplasty,     420, 

425. 

NEUMANN,  rhinoplasty,  413. 
NICOLADONI,  history  of  plastic  sur- 
gery, 7. 

NIEMAN,  cocain,  70. 
NOYES,  clamp  in  otoplasty,  127. 
VON  NUSSBAUM,  hair  transplanting, 

102. 
history  of  plastic  surgery,  7. 

OBERST,  meloplasty,  198. 
OLLIER,  ether,  safety  of,  64. 
history  of  plastic  surgery,  7. 


504 


INDEX    TO   AUTHORS 


OLLIER,  osteoplasty,  101. 
rhinoplasty,  417. 

PAGET,     heating     paraffin     syringe 

needle,  232. 
melting  point  of  paraffin,  241. 

PANCOAST,     history    of     roparative 
surgery,  5. 

PAQUEL,  antiseptics,  40. 

PARE,  AMBROSE,  history  of  rcpara- 
tive  surgery,  4. 

PARKER,  paraffin  injection,  210. 

PARKIIILL,    otoplasty    in    macrotia, 
135. 

PAVONI,      B.,      history      of      rhino- 
plasty, 3. 

PETRALI,  rhinoplasty,  359. 

PFANNENSTIEL,  embolism  from  par- 
affin injection,  209. 
pulmonary  embolism  from  paraffin 
injection,  224. 

PFLUGH,   hot-water   jacket  for   syr- 
inge, 233. 

VON  PFOHLSPUNDT,  history  of  rhino- 
plasty, 3. 

PHILLIPPEAUX,    history    of    plastic 
surgery,  6. 

PLESSING,  blepharoplasty,  10G. 

PONCET,     history     of     plastic     sur- 
gery, 7. 
osteoplasty,  101. 

PORTER,    Poplar    sawdust    dressing, 
48. 

Pozzi,  rhinoplasty,  456. 

POZZI-HAAGEDORN,  needle  holder,  78. 

PRAVAZ,  syringe,  72. 

PREIDELSBERGER,  rhinoplasty,  398. 

QUINLAN,  injection  of  paraffin,  210. 
paraffin  heater,  232. 

RANCKE,  antiseptics,  40. 
REDARD,  care  of  instruments,  15. 
REGUIEB,    skin    grafting    in    cheilo- 

plasty,  180. 
REVERDIN,    catgut,    preparation    of, 

32. 
history  of  skin  grafting,  6. 


REVERDIX,  skin-grafting  method,  89, 
107. 

RICARU,   history   of   reparative    sur- 
gery, 5. 

Ru'iiERAUD,  eheiloplasty,  1(58. 

RICHTER,  nasal  prothesis,   348. 

RiEoixiiER,   history   of   plastic    sur- 
gery, 7. 

ROE,  classification  of  nasal  deformi- 
ties, 212. 
rhinoplasiy,  4-17,  4(59. 

ROSE,  cheiloplasty,   151. 

classification  of  hare  lips,   147. 
stomatoplasty,  196. 

ROSER,  otoplasty,  120. 

ROTTER,  rhinoplasty,  393. 

Roux,    history    of    reparative    sur- 
gery, 5. 

SCHAFFER,  catgut  sterilization,  31. 
SCHEDE,  antiseptics,  38. 
SCHIMMEBUSCH,  dropping  bottle,  60. 

folding  mask,  61. 

rhinoplasty,  394. 

SCIILEICH,  cocain  solution,  71,  275. 
SCHULTZ,  W.,  antisepsis,  37. 
SCHWARTZE,    fracture    of    ear    car- 
tilage,  120. 

otoplasty  for  microtia,   134. 
SCIIWEIXIXGER,    hair   transplanting, 

102. 
SEBILEAU,  diffuse  fibromatosis  after 

paraffin  injection,  256. 
SEDILLOT,  cheiloplasty,  164. 

rhinoplasty,  383,  432. 
SEXN,  history  of  rhinoplasty,  7. 

osteoplasty,  101. 

SERRE,    history    of    reparative    sur- 
gery, 5. 

meloplasty,  199. 

rhinoplasty,  366,  445. 
SIMON,  cheiloplasty,  160. 
SMITH,  skin-grafting  scissors,  89. 
SMITH,  HARMON,  drop  syringe,  267. 

heating  needle  of  syringe,  232. 

nontoxic  effect  of  paraffin,  235. 

paraffin  heater,  246. 

paraffin  injection,  210, 


INDEX    TO   AUTHORS 


505 


SMITH,    HARMON,    redness    of    skin 

after  paraffin  injection,  248. 
safety  of  vaselin  injection,  218. 
tissue  replacement  of  paraffin,  235. 
SOISIERANSKI,    vaselin    injections    in 

animals,  217. 

SOCIN,  tinfoil  dressing  in  skin  graft- 
ing, !)(). 
SPICER,  diffusion  of  paraffin,  254. 

injection  of  paraffin,  210. 
SPRAGUE,  sterilizer,  26. 
STAFFEL,  meloplasty,  206. 
STEIN,   safety  of   vaselin  injections, 

218. 

subcutaneous  protheses,  209. 
tissue     replacement     by     paraffin, 

235. 
vein    puncture,    avoidance    of,    in 

paraffin  injection,  227. 
STEINIIAUSEN,  rhinoplasty,  412. 
STEINTHAL,  rhinoplasty,  377,  406. 
STRAUME,   vaselin   injection  in   ani- 
mals, 217. 
STUBENRATH,    vaselin    injections    in 

animals,  217. 

SUSRATA,  history  of  rhinoplasty,  2. 
SYLVESTER,     resuscitation     method, 

63. 
SYME,  cheiloplasty,  177. 

rhinoplasty,  367. 
SZYMANOWSKI,    history    of    repara- 

tive  surgery,  5. 
restoration  of  auricle,  12!). 
rhinoplasty,    303,    366,    375,    386, 
447. 

TADDIE,    vaselin    injection    in    ani- 
mals, 217. 
TAGLIACOZZI,    KASPAR,    history    of 

rhinoplasty,  3. 
harness,  87. 
rhinoplasty,  371. 
TEALE,  cheiloplasty,  185. 
TERRIER,  ethyl  bromid,  67. 
TIIIERSCII,    history    of    skin    graft- 
ing, 6. 

gauze  compress  dressings,  90. 
skin-grafting  razor,  93. 


TIIIERSCII,   skin  grafting   in   cheilo- 
plasty,  180. 
rhinoplasty,  381. 
THOMPSON,   rhinoplasty,  435. 
THORNDIKE,   mandilmlar   cleft,   infe- 
rior, 157. 

TRENDELENHUIU;,  cheiloplasty,  174. 
median    cleft    with    rhinophyma, 

147. 

TRIFFE,  rubber  apron,  19. 
TRIPIER,  blepharoplasty,   111. 

stomatoplasty,  194. 
TUFFIER,  secondary  elimination  par- 
affin, 262. 

UNNA,  zinc  oxid  plaster  mull,  48!). 

VASSERMAN,  gangrene  following 
vaselin  injection  in  nose,  222. 

VELPEAU,  nasal  amputation,   349. 

VERNEUIL,  rhinoplasty,  380. 

VIANEO,  VINCENT,  history  of  plastic 
surgery,  3. 

VINCI,  Beta  eucain,  74. 

VIOLLET,  electrothermically  heated 
syringe,  233. 

VOLKMAN,  rhinoplasty,  379. 

VULPIAN,  history  of  plastic  sur- 
gery, 6. 

WALCHER,  dressing  forceps,  55. 
WALLACE,  sterilizer,  25. 
WARREN,  history  of  reparative  sur- 
gery, 5. 

WEBER,  0.,  flap-twisting  method,  85. 
history  of  reparative  surgery,  2. 
needle  holder,  78. 
rhinoplasty,  434. 
VON  WECKER,  skin-grafting  method, 

107. 

WEIRICK,  skin-grafting  method,  97. 
WENDEL,  encystment  of  paraffin,  236. 
WENZEL,  encapsulation  of  paraffin, 

236. 
WHITE,  A.  C.,  liquid  air  anesthesia, 

74. 

WILDE,  polyotia,  138. 
WITZEL,  malformation  of  lip,  148. 


506 


INDEX   TO   AUTHORS 


WOLFE,  blepharoplasty,   106. 

history  of  skin  grafting,  G. 

skin-grafting  method,  !)1,   107. 
WOLFE,   J.,   history  of   plastic  sur- 
gery, 7. 

WOLFENDEN,  iodol,  42. 
WOLFF,  use  of  Hart  paraffin,  219. 


WOLFLEK,    mandihular    cleft,    lower 

lip  and  tongue,  150. 
mucosa -grafting,   101,  110,   105. 

ZAHN,  osteoplasty,  102. 
XEIS,  cheiloplasty,  181. 

history  of  reparative  surgery,  5. 


INDEX  TO   SUBJECTS 


Abscess,    due    to    paraflin    pressure, 

261. 
Alae,  reduction  of  thickened,   466. 

restoration  of,  427. 
Alar  deficiency,   312. 
Alcohol,  use  of,  35. 
Alcohol-chloroform  anesthesia,  67. 
Aluminium  acetate,  use  of,  35. 
Anesthesia,  combined,  66. 

alcohol-chloroform  in,  67. 
chloroform-ether  in,   67. 
chloroform-ether-alcohol   in,  67. 
ethyl  bromid,  67. 
ethyl  chlorid,  68,  69. 
general,  58. 

chloroform  in,  60. 
dropping  bottles  in,  60. 
ether  in,  63. 
masks  in,  61. 
preparation  for,  59. 
local,  69. 

cocain   in,   70. 
i'thyl  chlorid  in,  69. 
cucain,  beta,  in,  74. 
liquid  air  in,  74. 
stovain  in,  75. 
nitrous  oxid,  67. 

Angular  nose,  correction  of,  449. 
Ankyloblepharon,  operation  for,  116. 
Antiseptic  powders,  41. 
Antiseptic  solutions,  34. 
Antithermics,  indication  for,  57. 
Aristol,   use  of,  41. 
Artificial  mouth,  196. 
Auricle,  deficiency  aboiit,  334. 
malformation  of,  128. 
malposition  of,  138. 
restoration  of,  121. 


Auricle,   traumatism  of,   120. 
Auricular   appendages,    1:57. 
Auricular    lobule,   malformation   of, 

127. 

Auricular  prothcses,  125. 
Autodermic  skin-grafting,  88. 

Bandages,  removal  of,  49. 
Battery,  dry  cells,  477. 

portable,  476. 

wet  cell,  470. 
Benzoic   acid,   35. 
Blepharoplasty,      classification      of, 

103. 
Bone,  grafting  of,  101. 

Senn's  chips  of,   101. 
Boric  acid,  use  of,  35. 
Boric  acid  oil,  use  of,  55. 
Broadened   base   of   nose,   correction 

of,  465. 
Broadened     lobule,     correction     of, 

455. 

Bulbous  lobule,  correction  of,  455. 
Buccal  fissure,  150. 

Canthoplasty,   114. 

Carbolic  acid,  danger  of,  36. 

use  of,  35. 

in  face  peeling,  489. 
Cartilaginous   support  of  flaps,  use 

of,  404. 

Catgut,  preparation  of,  31. 
Cell,  electric,  470. 
Cell  selector,  473. 

arrangement  of,  474. 
Cells,  series  connection  of,  472. 
Cheek,  prothesis  for,  206. 
Cheek  compressor,  Hainsley,   161. 

507 


508 


INDEX    TO    SUBJECTS 


Checks,   deficiency  of,   321. 

surgery  of,   198. 
Cheiloplasty,   145. 
Chin,  receding,  329. 
Chloroform  anesthesia,  60. 
Chloroform-ether  anesthesia,  07. 
Chloroform-ether-ulcohol  anesthesia, 

67. 

Chromic   anhydrid,   37. 
Classification     for     indication     for 

protheses,  276. 
Classification  of  blepharoplasty,   103. 

of  deformities  of  lower  lip,  167. 
of  upper  lip,   162. 

of  hare  lip,   147. 

of  nasal  deformities,  212,  341. 

of  skin-grafting,  88. 
Coaptation,  sutureless,  45. 
Cocain,  in  local  anesthesia,  70. 

Schleich's  solution  of,  71. 
Collodium  dressing,  44. 
Coloboma,  correction  of,  125. 
Compression  forceps,   145. 
Corneal  graft,  7. 
Cosmetic  rhinoplasty,  448. 
Creolin,  use  of,  37. 

Decortication  method,  488. 
Deficiency,  about  alae,  312. 

about  cheeks,  321. 

about  chin,  329. 

about  ears,  334. 

about  lips,  314. 

about  nose,  286. 

about  subseptum,  313. 

labial,  184. 

of  nasal  lobule,  464. 

of  vermilion  border,  190. 
Deformities,  about  the  mouth,  314. 

of  the  nose,  286. 

classification  of,  212. 
Dermatol,  use  of,  41. 
Deviation,  nasal,  correction  of,  467. 
Diffusion   of   injected   paraffin,   228, 

252. 

Disinfection  of  operating  room,  10. 
Dissection,  subcutaneous,  2. 
Dressing  forceps,  55. 


Dressing  of  wounds,  43. 
Dressings,  changing  of,  48. 

sterilization  of,  24. 
Dropping     bottles,     for     anesthesia, 
60. 

Ear,  surgery  of,  120. 
Ectropion,  blepharol,  103. 
correction  of,  104. 

labial,  186. 
Electric  battery,  470. 
Electric  tattooing  needle,  487. 
Electric  wall  plate,  475. 
Electrodes,  477. 

arm,  478. 

multiple  needle,  484. 

sponge,  477. 

Electrolysis  in  dermatology,  470. 
Electrolytic  needle  holder,  479. 
Electrothermic  paraffin  heater,  244. 
Elevated  lobule,  correction  of,  454. 
Embolism,    after   paraffin   injection, 

223. 

Entropion,  labial,  189. 
Epicanthus,  operation  for,  113. 
Epilating  forceps,  481. 
Ether  anesthesia,  63. 
Ether  inhalers,  65. 
Ethyl-bromid  anesthesia,  67. 
Ethyl-chlorid,  use  of,   in   prothcses, 

273. 

Ethyl-chlorid  anesthesia,  68. 
Eucain,  beta,  use  of,  74,  272. 
Eucalyptol,  use  of,  37. 
Exfoliation  of  facial  skin,  488. 

Face  peeling,  489. 

Facial  cleft,  bilateral,  149. 

unilateral,  149. 
Facial  pits,  removal  of,  488. 
Fibrolysin,  use  of,  488. 
Fibromatosis,    after    paraffin    injec- 
tion, 256. 

microphotographs  of,  257. 
Flap    method,    combined,    in    rhino- 
plasty, 378. 
Flaps,  implantation  of,  87. 

nasal,  cutting  of,  345. 


INDEX    TO    SUBJECTS 


509 


Flaps,    nasal,    organic    support    of, 
3.S7,  38!),  390. 

pedunculated,  care  of,  50. 

transplantation  of,  88. 
Forceps,     Burchardt's    compression, 
145. 

dressing,  55. 

epilating,  481. 
Forehead,  receding,  280. 
Foreign  bodies,  51. 
Formaldehyd  disinfection,  10. 
French  method  in  rliinoplasty,  3C3. 
Furrow,  about  canthi,  326. 

interciliary,  279. 

nasolabial,  317. 

oral-angular,  320. 

Gangrene,  symptoms  of,  54. 

treatment  of,  55. 
Glycerin,  use  of,  37. 
Granulation  of  wounds,  47. 

Hair,  transplantation  of,  102. 
Hairs,  electrolytic  removal  of,  480. 
Hands,  preparation  of,  1C. 
Harelip,  cause  of,  146. 

classification  of,  147. 

correction  of,  150. 

post-operative   treatment  of,    161. 
Harelip  clamp,   145. 
Harness,  Tagliacozza,   87. 
Hemorrhage,  control  of,  49. 
Heterodermic  skin-grafting,  88-96. 
Hindoo  method,  in  rhinoplasty,  351. 
Hydrogen  peroxid,  39. 
Hyperinjection  of  paraffin,  221. 

Infection,    erysipelatous,    cause    of, 

56. 

treatment  of,  57. 
lodin,  use  of,  39. 
lodoform  gauze,  use  of,  57. 
lodol,  use  of,  41. 
Instruments,  care  of,  14. 
Interlobular  deficiency,  310. 
Irrigation,  method  of,  15. 
Italian  method,  in  rhinoplasty,  369. 
Ivory  bone  protheses,  101. 


Koloid,   120. 

Koomas   rhinoplasty,  352. 

Labial  deficiency,  184,  314. 

Labial  ectropion,  186. 

Labial  entropion,   189. 

Lids,  surgery  of,  103. 

Ligatures,  30. 

Lips,  surgery  of,   145. 

Liquid  air  anesthesia,  74. 

Lobule,  bulbous,  correction  of,  455. 

correction  of,  455. 

deficiency  of,  464. 

elevated,  correction  of,  454. 

nasal,  restoration  of,  423,  441. 
Lysol,  use  of,  39. 

Macrostoma,  150. 

correction  of,  192. 
Macrotia,   132. 
Malformation,  of  auricle,  128. 

.of  auricular  lobule,  127. 
Malposition  of  auricles,  137. 
Maxillary    process,    prominent,    cor- 
rection of,  468. 
Masks,  anesthetic,  61,  65,  66. 
Meloplasty,  198. 
Melting  points  of  paraffin,  239. 
Mercurial  toxemia,  38. 
Mercury  bichlorid,  use  of,  38. 
Microstoma,  correction  of,  195. 
Microtia,    129. 
Milliamperemeter,   475. 
Moles,  removal  of,  482. 
Mouth,  artificial,   196. 

deformities  of,   314. 

surgery  of,  192. 
Mucosa,  grafting  of,  101. 
Mucosa  wounds,  care  of,  50. 
Multiple  needle  electrode,  484. 

Naevi,  removal  of,  484. 
Nasal  chisels,  453. 
Nasal  deficiencies,  286. 
Nasal  deformities,  286. 
classification  of,  341. 
Nasal  destruction,  cause  of,  341. 
Nasal  deviation,  correction  of    467. 


510 


INDEX   TO    SUBJECTS 


Nasal  flaps,  cutting  of,  345. 

Nasal  mallet,   453. 

Nasal  protheses,  external,  347. 

Nasal  replanting,  348. 

Nasal  retention  apparatus,  385. 

Nasal  transplanting,  349. 

Nasal  width,  correction  of,  468. 

Nasolabial  furrow,  317. 

Nausea,   after   local   anesthesia,   73. 

Needle  holders,  77. 

electrolytic,  479. 
Needles,  Haagedorn,  77. 

tattoo,  487. 

Nitrous  oxid  anesthesia,  67. 
Nose,  broad  base  of,   correction  of, 
465. 

surgery  of,  339. 

Ocular  stump,  deficiency  of,  327. 
Ohm's  law,  471. 

Operating  room,  requisites  for,  9. 
Operations,  number  of,  about  nose, 

346. 

Operative  field,  preparation  of,  20. 
Oral-angular  furrow,  320. 
Orbit,  deficiency  about,  324. 
Organic  support  of  nasal  flaps,  387, 

389,  390,  404. 
Orthoform,  use  of,  42. 
Osteoperiostitic  support  of  flap,  390. 
Otoplasty,  120. 
Oxid,  nitrous,  anesthesia  by,  67. 

Paraffin,  diffusion  of,  228. 
secondary,   252. 

hyperinjection  of,  221. 

melting  point  of,  239. 

subinjection  of,  221. 
Paraffin     compound     for     injection, 

244. 

Paraffin  embolism,  223. 
Paraffin  heater,  232,  244,  246. 
Paraffin    injection    for    epicanthus, 

113. 

Paraffin  syringe,  Eckstein,  232. 
Pedunculated  flaps,  care  of,  50. 

implantation  of,  87. 
Periostitic  support  of  flap,  389. 


IVrnxcls,  use  of,  41. 
Photographic  printing,  497. 
Photographs,     in     recording     cases, 

491-496. 
Plaster,  protective,  44 

removal  of,  44. 

Z.  0.,  47. 

Plaster  casts,  making  of,  403. 
Plastic   operations,  methods   in,   79. 

principles  of,  70. 
Polyotia,  137. 

Postauricular  deficiency,  335. 
Potassium  permanganate,  use  of,  39. 
Powders,  antiseptic,  41. 
Pressure  abscess,  261. 
Principles  of  plastic  surgery,  76. 
Pro-auricular  deficiency,  334. 
Protheses,  auricular,  125,  130. 

classification    for     indication    of, 
276. 

external,  8. 
nasal,  347. 

of  cheek,  206. 

practical  technique  of,  272. 

subcutaneous,    indication    for,    8, 

209,  210. 

precautions  in,  213. 
untoward  results  in,  216. 
Ptosis,  operation  for,   115. 
Pus,  laudable,  51. 

Razors,  skin-grafting,  93. 
Receding  forehead,  280. 
Redness   of    skin    after    paraffin   in- 
jection, 248. 
Replanting  nose,   348. 
Retention  apparatus  for  nose,  385. 
Rheostat,  471. 
Rhinophyma,  147. 
Rhinoplasty,   339. 

French  method  of,  363. 

Hindoo  method  of,  351. 

Italian  method  of,  369. 

Koomas  method  of,  352. 

partial,  412. 

technique  of,  344. 

Round  cell  infiltration  after  paraffin 
injection,  258. 


INDEX    TO    SUBJECTS 


511 


Rubber     stamp     recording 
493. 

Salicylic  acid,  use  of,  40. 
Scars,  removal  of,  485. 

treatment  of,   48(5. 
Scissors,  probe  pointed,   114. 

curved  eye,  117. 
Septica-mia,  52. 

treatment  of,  53. 
Series  connection  of  cells,  472. 
Shoulders,  deficiency  of,  contour  in, 

336. 

Shunt  rheostat  connection,  473. 
Skin-grafting,  88. 

classification  of,  88. 

dermal,  6. 

epidermal,  6. 

general  remarks  on,  100. 

in  blepharoplasty,  107. 

method  of,  89. 
Skin-grafting  razors,  93. 
Skin-grafting  scissors,  89. 
Sodium  chlorid,  use  of,  40. 
Solutions,  antiseptic,  34. 
Spartein,  use  of,  57. 
Sponge  electrode,  477. 
Sponges  and  sponging,  22. 
Stencil  recording  methods,  492. 
Stitch  scars,  45. 
Stomatoplasty,  192. 
Stovain  anesthesia,  75. 
Subcutaneous  dissection,  2. 
Subseptal  deficiency,  313. 
Subseptum,  restoration  of,  443. 
Superfluous  hairs,  removal  of,  480. 
Sutureless  coaptation,  45. 
Sutures,   and  their  care,  30. 

placing  of,  76. 


Syringe,  Eckstein,  232. 
Kolle,   72,  26.y-2(i«i. 
Pravaz,  72. 
Kolle  "  Simplex,"  72. 
"Sub  Q,"  72. 
Smith,  207. 

Tattoo-marks,  removal  of,  485. 
Telangiectasis,  treatment  of,  4S3. 
Thiosinamine  solution,   use  of,  488. 
Thymol,  use  of,  40. 
Transplanting  of  nose,  349. 
Traumatism  of  auricle,  120. 

Unna  plaster  mull,  use  of,  489. 
Untoward  results   in  paraflin  injec- 
tion, 216. 

Vacuoles,    result    of    paraffin    injec- 
tion, 258. 
Voltage  of  cells,  471. 

Wall  plate,  electric,  475. 
Wall  plate  connections,  475. 
Wound  dressings,  43. 
Wounds,  granulation  of,  47. 

of  mucpsa,  50. 
Wrinkled  eyelids,  operation  for,  116. 

Xanthelasma     palpebrarum,     opera- 
tion for,  118. 

Yellow  appearance  of  skin  after  par- 
affin injection,  259. 

Zinc  chlorid,  use  of,  40. 
Z.  0.  plaster  strips,  47. 
Zoocorneal  graft,  7. 
Zoodermic  skin-grafting,  88,  97. 


THE   END 


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Plastic  and  cosmetic  surgery 


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1911 

Colle,  Frederick  Strange. 
Plastic  and  cosmetic  surgery 


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